Permission to Administer Medication in School
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3000 West School House Lane ( Philadelphia, Pennsylvania 19144 ( 215-844-3460 ( | |
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| |Health Office |
Permission to Administer Medication in School
Medications will be administered in school when there is specific written permission from the parent and the health care provider. The medication must be delivered in the original labeled container to the health office by the parent accompanied by this completed form.
Date: ____________________
Student Name: __________________________ DOB: ________________ Grade: ____
Diagnosis: __________________________________________________
Medication Name & Dose: _____________________________________
Route of Administration: _______________________________________
Time of Administration: ________________________________________
Duration of Administration: _____________________________________
Possible Side Effects: _________________________________________
Other instructions: ____________________________________________
Signature of Parent/Guardian: ___________________________________
Signature of Prescribing Physician: _______________________________Phone # _____
Address ______________________________________________________
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