Medication Permission Form (For all over-‐the-‐counter and/or prescribed medications)
Student:___________________________________________________________ Date form received:________________________________
Date of Birth:__________________________________ Grade/Teacher:_________________________________________________________
To be completed by the physician:
Name of Medication:______________________ Reason for medication (optional):_____________________________________ Form of medication/Treatment: _______Tablet/capsule _______Liquid _______Inhaler _______Injection _______Nebulizer _______Other Start: Date form received:________________________________________Other dates:__________________________________ Stop: End of school year:________________________________________ Other date/duration:________________________ Restrictions and/or important side affects: ______None anticipated ______Yes (describe below)
Special storage requirements: ______None ______Refrigerate ______Other:_______________________________________ The student is both capable and responsible for self-‐administering this medication: ______Yes ______Yes-‐Supervised ______Yes-‐Unsupervised Physician name:__________________________________________________________________________________________________________ Address:______________________________________________________________________________Phone:____________________________ Date:__________________________Signature:_________________________________________________________________________________
To be completed by the parent/guardian:
I request that (student name)_____________________________________________________________________received the above medication at school according to school policy. I request that (student name)_____________________________________________________________________be allowed to self-‐ administer the above medication at school according to school policy. Date:____________________Signature:_________________________________________________________Relationship:______________