Permission to Administer Medication in School



[pic] |

3000 West School House Lane ( Philadelphia, Pennsylvania 19144 ( 215-844-3460 ( | |

| | |

| |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 ______________________________________________________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download