Medical Information forms

  • HENDRICK HUDSON SCHOOL DISTRICT MEDICATION AUTHORIZATION FORM Parent and Prescriber’s Authorization for Administration of Medication in School A. To be completed by the parent or guardian: I request that my child, ____________________________________ grade____, receive the medication as prescribed below by our licensed health care prescriber. The medication is to be furnished by me in the properly labeled original container from the pharmacy. I understand that the school nurse will administer the medication or an adult will supervise my child taking his/her own medication. Signature (Parent or Guardian): ________________________________________ Address: __________________________________________________________ Phone: Home __________________ Work: _____________ Date: ____________ B. To be completed by the licensed health care prescriber: I request that my patient, as listed below, receive the following medication: Name of Student: ___________________________ Date of Birth: ____________ Diagnosis: ________________________________________________________ Name of Medication: ________________________________________________ Prescribed Dosage, Frequency and Route of Administration: _________________________________________________________________ Time to be taken during School Hours: __________________________________ Duration of Treatment: _______________________________________________ Possible Side Effects and Adverse Reactions (if any): ______________________ _________________________________________________________________ Other Recommendations: ____________________________________________ Name of Licensed Prescriber and Title (please print): ______________________ Prescriber’s Signature: ___________________________ Date: _____________ Address: ______________________________________ Phone: ____________