LSCHS_Medication_Consent_Form.pdf
La Salle College High School8605 Cheltenham AvenueWyndmoor, PA 19038 Telephone: 215?233?2911Fax: 215?233?1418MEDICATION CONSENT FORMThe Pennsylvania Department of Health has issued new guidelines concerning the dispensing of medication in school. In order to dispense any prescription or non?prescription drugs, La Salle College High School must have a permission form signed by a parent AND PHYSICIAN on file in the Nurse’s Office.Please check the appropriate lines below, sign and return to La Salle College High School c/o Nurse Office Your child will be given no medication without this signed form.STUDENT’S NAME ______________________________________________________________ The following medication may be dispensed:_____ Tylenol or Advil for a headache_____ Gelusil tablet for an upset stomach_____ Robitussin DM for cough_____ Sudafed for allergies_____ Other ______________________________________________________________________________________________________________________________________Physician’s SignatureParent’s SignaturePRESCRIPTION MEDICATIONName of medication ___________________________________ Dosage ________________Time to be administered _______________ Length of time given ___________________Possible side effects _________________________________________________________________________________________________________________________________DateTelephonePhysician’s Signature____________________________________________________________________DateTelephoneParent’s SignaturePlease return to: La Salle College High School c/o Nurse Office prior to the start of the school year. Thank you. ................
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