Physician's Medication Order Form
PERMIT FOR DISPENSING PRESCRIPTION/NON PRESCRIPTION MEDICATION TO STUDENTS BY SCHOOL PERSONNEL
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 ______________________
FOR ________________________________________________ PERSONNEL
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 ___________________________________