Shenandoah Valley Adventist Elementary

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Physician's Medication Order Form
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                                                                                                                                    PPM2008
 
PERMIT FOR DISPENSING PRESCRIPTION/NON PRESCRIPTION MEDICATION TO STUDENTS BY SCHOOL PERSONNEL
 
PARENT REQUEST
 
I am the parent, guardian, or caretaker in charge of _________________________________________. I am requesting the following medication be given to this student, according to instructions provided by the physician as described, and have read the policy of  SVAE pertaining to the administration of medication to students at school.
 
 
Signature ______________________________________           Date ______________________
 
 
PHYSICIAN’S STATEMENT
 
 
FOR ________________________________________________ PERSONNEL
                                             (School Name)
 
Since medication for the student listed below cannot be scheduled for other than school hours and administration of such prescribed medication may be supervised by medically untrained personnel, it is requested that the medication as indicated below be administered by school personnel.
 
Name of Student _______________________________________ Birthday _______________________
 
Address ______________________________________________ Telephone _____________________
 
Diagnosis, name of medication, dosage, and explicit instructions for administration.
 
_____________________________________________________________________________________
 
_____________________________________________________________________________________
 
Date administration is to begin _________________________ Date to cease ______________________
 
Severe adverse reactions that should be reported to the physician:
 
_____________________________________________________________________________________
 
_____________________________________________________________________________________
 
One or more phone numbers where the physician can be reached in case of any emergency:
 
             ___________________         ______________________       ____________________
 
Date ________________________ Physician’s Signature ___________________________________