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SIU Family and Community Medicine Anna Jonesboro

School Health Center

“Over-The-Counter” Medication Dispensation Authorization Form

Child’s Name: ______________________________

Date of birth: ______________Grade: __________

Parent/Guardian: ___________________________

Best phone #: ______________________________

Below is a list of over-the-counter medications (and/or their generic equivalent) used by the SIU Family and Community Medicine Anna Jonesboro School Health Center nursing service:

Tylenol: headache, menstrual cramps or musculoskeletal pain (if can’t take ibuprofen)

Motrin: headache (if no head trauma), menstrual cramps, musculoskeletal pain, tooth pain

Midol- menstrual cramps

Benadryl: allergic reaction, allergies, itching

Zyrtec: allergic reaction, allergies, itching

Tums/Pepto Bismol: nausea, abdominal cramping, heart burn, (we ensure no fever before giving)

Immodium/Gas X- diarrhea without fever, gas or bloating

Cepacol lozenges: sore throat

Cough drops/ Robitussin cough syrup: cough

Sudafed: congestion, common cold symptoms

Eye Drops- Dry, irritated, itching eyes (not pink eye)

Solarcaine/ Burn spray- minor burns, sunburns

Carmex- Dry cracked lips

Icy Hot- muscle pain

Calaclear/ Calamine- Poison Ivy

Glucose tablets: low blood sugar of known diabetic

Hydrocortisone cream: applied to certain rashes that itch or bug bites

Triple Antibiotic ointment: cuts, dressing wounds

Contact solution: contact issues

Normal saline: clean wounds

Rubbing alcohol: clean piercings

Orajel: tooth pain

Hydrogen peroxide: clean dirty wounds

By signing below (please initial EACH):

_____ I request and consent to the dispensation of the previously listed medications (generics used for cost savings) for the previously listed reasons.

Please check mark one:

o Give as needed.

o Do not give.

_____ I hereby release and hold harmless the SIU Family and Community Medicine Anna Jonesboro School Health Center, SIU Family Medicine, SIU School of Medicine, SIU HealthCare and AJCHS from any and all liability for acting in conformance with this authorization and consent and in a manner consistent with the reasonable standards of care in the community under these circumstances. Parent/Guardian/Child has the right to refuse services.

_____ I understand these services will be documented in the student school health record.

_____ I understand this consent applies to the child’s entire high school career. I can make changes in writing or by completing a new form.

Please sign below:

__________________________________________

Parent/Guardian signature

Date: ____________________

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