Administration Of Medication Consent Form printable pdf download

SAGINAW TOWNSHIP COMMUNITY SCHOOLS

ADMINISTRATION OF MEDICATION CONSENT FORM

Student’s Name______________________________________________________

Birthdate___________________Grade____________Today’s Date_____________

Medication Information

(To be completed by Health Care Provider)

Name of Medication________________________________________

ddddddd

Purpose of Medication______________________________________

Dosage____________________Route & Frequency______________

Expiration Date_________Time to Administer Medication_________

Directions for Administration_________________________________

Length of Time Medication will be prescribed____________________

Side Effect of Medication/Comments___________________________

Restrictions

Yes

If yes, what and how long?_____________________



For Inhaled/Injected Medication- Asthma Management Plan/Allergy Action Plan Completed

I have instructed student in the proper way to use his/her inhaler/Epi Pen. It is my



professional opinion that he/she be allowed to carry and use the inhaler/Epi Pen by

him/herself.



It is my professional opinion that the student should not carry or administer inhaler/Epi Pen

by him/herself.

Attending Physician_____________________________________Date____________

Signature

Printed Name & Address of Physician_________________________________________

I hereby request that my child be administered the prescribed medication at school by designated school personnel. I

understand that the medication will be administered as per the directions of the above named physician. I will notify the

school of changes or discontinuance of this medication(s) immediately

Parent/Guardian________________________________________Date____________

signature

Address_______________________________________________Phone___________

M.C.L.A. S 380.1178 states the following “ a school administrator, teacher or other school employee designed by the

school administrator, who in good faith administers medication to a pupil in the presence of another adult pursuant to

written permission of the pupil’s parent or guardian and in compliance with the instructions of the physician is not

liable in criminal action or for civil damage as a result of administration except for an act or omission amounting to

gross negligence or willful and wanton misconduct.” File in CA60

Administration Of Medication Consent Form