Form M-1 - Physician'S Medication Order Form - Meritus Health School Health Program printable pdf download

MERITUS HEALTH SCHOOL HEALTH PROGRAM

WASHINGTON COUNTY PUBLIC SCHOOLS

PHYSICIAN’S MEDICATION ORDER FORM

Attach

TO BE COMPLETED BY PARENT/GUARDIAN

Photo

Student Name: _________________________________________________________________ Date of Birth: __________________

School: ___________________________________________ Grade: _________ School Year

: ______________

(including Summer School)

uuu PLEASE USE A SEPARATE FORM FOR EACH MEDICATION uuu

A NEW FORM MUST BE COMPLETED AT THE BEGINNING OF EACH SCHOOL YEAR!

TO BE COMPLETED BY PHYSICIAN OR AUTHORIZED PRESCRIBER

Name of medication: _________________________________________________ Allergies: ______________________________________________

Reason for medication: _____________________________________________________________________________________________________

Form of medication/treatment:

 Tablet/Capsule

 Liquid

 Inhaler

 Injection

 Nebulizer

 Other _____________________________________

Instructions (Time to be given at school): ________________________________________________________________________________________

Dose (mg, ml, ml/tsp, # puffs) _________________________________________________ Route_____________________________________

If PRN, for what symptom(s) _________________________________________ If PRN, frequency _______________________________________

Side effects: (Please describe) ________________________________________________________________________________________________

Please check one of the following:

Discontinue:

 End of school year

 Other (specify): ____________________________________________________________________

The order must match the prescription label.

Please note: Any deviation from the scheduled time requires a new order.

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This includes delayed openings, early dismissals or field trips.

Authorized Prescriber’s Signature: ______________________________________________________________________ Date: ___________________

Authorized Prescriber’s Name/Title: ________________________________________ Phone: _____________________ Fax: _____________________

(Type or Print)

A verbal order was taken by the school RN (name) ___________________________________ for the above medication on (date) __________________

Verbal order must be followed by a signed order within 1 day.

For Self-Administration ONLY

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TO BE COMPLETED BY PHYSICIAN OR AUTHORIZED PRESCRIBER

TO BE COMPLETED FOR INHALER OR EPI-PEN ONLY

Washington County Board of Education permits a student to possess and self-administer asthma or anaphylaxis medication at school and

at school-related functions. Completion of the following information by the authorized prescriber acknowledges that this student has been

instructed and has the skills and knowledge on self administration of this medication.

This student may carry this medication:

 No

 Yes

Signature: ______________________________________________________________________________________ Date: _____________________

(Authorized Prescriber’s Signature)

PARENT TO COMPLETE EPI-PEN/INHALER CONTRACT ON BACK OF THIS FORM

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TO BE COMPLETED BY PARENT/GUARDIAN

I give permission for (name of child) _____________________________________________ to receive the above stated medication at school according

to standard school policy. I release Meritus Health, the Washington County Board of Education, and their employees from any claim or liability for

administering prescribed medication to this student. I HAVE READ THE INFORMATION OUTLINED ON THE BACK OF THIS FORM AND ASSUME THE

RESPONSIBILITIES AS STATED ON THIS FORM. I authorize the school nurse to communicate with the health care provider as allowed by HIPAA.

Date: ________________ Signature: __________________________________________________ Relationship: _____________________________

Home phone: ___________________________ Work phone: ___________________________ Emergency phone: ___________________________

Order reviewed by the school RN ___________________________________________________________________________ Date ___________________

Form M-1 (14)

Form M-1 - Physician'S Medication Order Form - Meritus Health School Health Program

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