Gfps GREAT FALLS PUBLIC SCHOOLS
gfps GREAT FALLS PUBLIC SCHOOLS
PHYSICIAN’S RECOMMENDATION
FOR ADMINISTERING PRESCRIPTION
MEDICATION
We are aware that at times it may be necessary for a student to take prescription medications while at
school. It is preferred, if at all possible, that medication be administered at home. In the event it is
absolutely necessary that the student take medication during the school day, this form must be completed and signed by the physician prescribing the medication. The form must also be signed by the parent
or guardian before the student can begin taking the medication at school.
**************************************
Physician’s Prescriptive Directions: Please describe the medicine, the dosage, at what time it
should be administered, the purpose of the medication and anticipated amount of time on medication.
Patient’s Name: ____________________________________________________________________
Medication: ________________________________________________________________________
Dosage: ___________________________________________________________________________
Time: _____________________________________________________________________________
Purpose: __________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________ ______________________________
Physician Signature Date
________________________________________________________________________________
Parent Information/Permission: The staff responsible for ________________________________________
has my permission to assist with self-administration of the medication as prescribed by above physician.
_________________________________________ _______________________________
Parent/Guardian Signature Date
________________________________________________________________________________
Parent: Please list below any medications not listed above that are taken at home whether they are prescription or over the counter medications. This information is required in the event of an emergency medical situation while at school.
Before emergency medical services can be performed it is important to know what medication the child may have taken that day.
SP-89 Revised 4/05
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Name of Medication Dosage Time
................
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