MEDICATION ORDER

(To be completed by a Licensed Prescriber:

Physician, Nurse Practitioner or others authorized by Chapter 94C)

 

Name of Student______________________________Date of Birth_________________

 

Address_______________________________________________________Grade_____

                        (street)                                  (city/town)

 

Name of Licensed Prescriber_____________________________Title_______________

 

Business Phone________________________Emergency Phone____________________

 

Medication______________________________________________________________

 

Route of Administration_____________________Dosage_________________________

 

Frequency________________Time(s) of Administration__________________________

(Please note: whenever possible, medication should be scheduled at times other than school hours).

 

Specific directions or information for administration:_____________________________

                                                                                                                                                

 

Date of Order____________________Discontinuation Date_______________________

 

Diagnosis*______________________________________________________________

 

Any other medical condition(s)*_____________________________________________

 

Optional Information

 

  1. Special side effects, contraindications, or possible adverse reactions to be observed:___________________________________________________.
  2. Other medication being taken by the student:_____________________________________________________.
  3. The date of the next scheduled visit or when advised to return to prescriber:___________________________________________________.
  4. Consent for self-administration (provided the school nurse determines it is safe and appropriate).  Yes_________________No_________________________.

 

Signature of Licensed Prescriber___________________________________________

 

Date_________________________________________________________________

 

*If not in violation of confidentiality

4/03 KP