Download/Print Copy of Physician Order Form

Physician Order

Download/Print Copy of Physician Order Form

Permission For Medication To Be Given At School

1. Name of Student
   • School
   • Grade
   • Teacher
2. Diagnosis
   • Medication
   • Dosage
   • Purpose of Medication
   • Time of Day Medication Is To Be Given
   • Anticipated Number of Days To Be Given At School
   • Additional Instructions
3. Date
   • Signature of Physician or Healthcare Provider
   • Clinic Name

Parental Consent

I hereby give my permission for [student name] to take the above medication at school as ordered.  I understand that is it my responsibility to furnish this medication.  I authorize the release and exchange of information concerning this medication between my child's physician and the school.

• Date
• Signature of Parent or Guardian

 

Note: The prescription medication is to be brought to school by the parent or guardian in a container appropriately labeled by the pharmacy, or physician, stating the name of the student, the name of the medication, and the dosage.

It is the parents or guardians responsibility to pick up all medications by the last day of school or it will be disposed of.