Authorization for Prescription Medications

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Authorization-for-Prescription-Medication.pdf Popular 511.6 KB

05/30/2020 10:42

To be taken during school hours

The following must be completed by the parent

Student Information

First Name(*)

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Last Name(*)

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Date of Birth

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Grade

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Homeroom Teacher

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Physician's Name(*)

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Physician's Phone

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Pharmacy Name(*)

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Pharmacy Phone

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Details about Medicine

Upload a photo of the prescription information

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Diagnosis for which medication is given

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Name of medication

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Form

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Dose

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If daily, what time

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If "as needed," describe indications

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How soon can it be repeated?

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Is the child authorized to medicate himself?

YesNo Invalid Input

List significant side-effects

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Length of time this treatment is recommended

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Any other relevant information

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