Individualized Standing Orders Form printable pdf download

INDIVIDUALIZED STANDING ORDERS

Name: _______________________________ Date of Birth:

/Camp Session: ________________

A: TO BE COMPLETED BY THE LICENSED HEALTH CARE PROVIDER:

Standard Over-the-Counter/PRN Medications – The following medications are available in the Camp Health Office

and will be administered at the discretion of an EMT, if approval is indicated by the camper’s health care provider.

Dosage and schedule will be per label by age/weight.

Doctor’s Order

Drug Name

Route

Comment

Check one

YES

Tylenol (Acetominophen)

PO – tablet

Fever >_______ºF

Advil/Motrin (Ibuprofen)

PO – tablet

Fever >_______ºF

Benadryl (Diphenhydramine Hydrochloride)

Bacitracin or Neosporin Ointment

Topical ointment

Calamine or Campho-phenique

Lotion

Solarcaine or Nupercaine burn spray

Liquid spray

Dimetapp

PO - elixir

Pepto Bismol

Sucrets or Chloraseptic Lozenges

PO – lozenge

Tylenol Cold

PO – tablet

Milk of Magnesia

Robitussin DM Cough Syrup

PO – syrup

Dacriose

Rinse – eye

Tums

Tablets

Murin or Visine eye drops

Eye drop

Rhuli Gel or Hydrocortisone Ointment

Topical ointment

Kaopectate

Prescription Medications – Please complete the patient’s current regimen for both scheduled and PRN

medications.

Drug

Route

Dosage

Schedule and Indications

Comments

Health Care Provider’s Name: _________________________________ Phone: (

)

Address: __________________________________________________ License #: ________________________

Health Care Provider’s Signature: ____________________________________________ Date:

B: TO BE COMPLETED BY PARENT OR GUARDIAN:

I request that my child _______________________ receive the medication as prescribed by our licensed health

care provider. Prescription medications and any over-the-counter medications not made available by the camp are

to be furnished by me in the properly labeled container from the pharmacy. I understand that the camp medical

officer will supervise the administration of the medication.

Parent’s Signature: ____________________________________________________ Date:

COPY AS NEEDED

Individualized Standing Orders Form

Related Articles

Related forms

Related Categories