request for medication to be given during school hours

REQUEST FOR MEDICATION TO BE GIVEN DURING SCHOOL HOURS (Spanish)
This request must be signed by parent/guardian and physician to authorize medication during school hours.
The section in English is for the physician and the Spanish section is to be completed by parent or guardian.
SCHOOL NAME: _____________________________________Fax: _______________________
TO BE COMPLETED BY PHYSICIAN:
Pupil’s Name __________________________________________ Grade ________ Diagnosis ____________________________
Medication ____________________________________________ Dosage __________________________ Route ____________
Time to be given ________________________________________ Purpose of Medication ________________________________
Significant information: (include side effects and toxic reaction)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Duration of order: From ___________________________________ to ______________________________________________
___ Yes
___ No If medication is used for asthma/allergic reaction (ie: inhaler/epipen), I certify this student has been taught to
self-administer and should be allowed to carry own medicine and use as prescribed.
____________________________________________
Physician’s Name (please print)
___________________________________________
Physician’s Signature
____________________________________________
Date
___________________________________________
Telephone Number
Spanish version below signed by parent indicates the following: I request that my child be administered the medication as indicated
in the physician’s order above. I understand that non-medical personnel conduct the administration. If an emergency injection is
ordered, I give permission for the School Nurse to instruct designated staff in the administration technique. I understand that it is my
responsibility to furnish this medication within a container properly labeled by a pharmacist with identifying information, e.g., name
of child, medication dispensed, dosage prescribed and the time it is to the given and to transport the medication to school unless
special arrangements are made. I authorize the release and exchange of medical and educational information between my child’s
physician and school staff that is necessary in carrying out this service to my child.
PARA LLENARSE POR PADRE/MADRE/TUTOR:
Solicito que a mi hijo/a se le administre el medicamento como indicado en las órdenes del doctor arriba en este formulario.
Comprendo que personal no-médico va administrar el medicamento. En caso de órdenes para una inyección en caso de
emergencia, yo doy permiso a la Enfermera Escolar a dar instrucciones para la administración técnica al personal designado.
Comprendo que es mi responsabilidad proveer el medicamento en la botella de la farmacia con información en la etiqueta indicando
el nombre del niño, el medicamento, la dosis y la hora para dar el medicamento y yo soy responsable por el transporte del
medicamento a la escuela a menos que se hacen arreglos especiales.
Yo autorizo el intercambio de información médica y educativa que sea necesario entre el doctor y el personal escolar para llevar a
cabo este servicio para mi hijo/a.
____________________________________
Firma de Padre/Madre/Tutor
_____________________________
# de Teléfono/Celular
Health-Request for Medication during School Hours Revised 06-2010
_______________________
Fecha