Form: (i.e. tab, injection, etc.) Dose: Time of Administration: If medicine to be given “when needed.” Describe indications: How soon can it be repeated? Is child authorized to medicate herself/himself? List significant side effects: Length of time this treatment is recommended: Must this medication be administered during the school day in order to allow the child to attend school or to address the medical condition that may arise at student’s Yes No school? ____________ _______________________________ ___________________ Date Signature Telephone Only Physician’s Physician’s Initials___________ Nurse’s 11 December
Form: (i.e. tab, injection, etc.) Dose: Time of Administration: If medicine to be given “when needed.” Describe indications: How soon can it be repeated? Is child authorized to medicate herself/himself? List significant side effects: Length of time this treatment is recommended: Must this medication be administered during the school day in order to allow the child to attend school or to address the student’s medical condition that may arise at school? Yes No ____________ _______________________________ ___________________ Date Physician’s Signature Only Physician’s Telephone Nurse’s Initials___________ 11 December