BFHS_EpiPen_Benadryl_Authorization_Form

BISHOP FENWICK HIGH SCHOOL EPIPEN AND BENADRYL AUTHORIZATION FORM

School Year: ____________________ This form authorizes designated school personnel to administer Epinephrine (EpiPen) and/or Benadryl to a student in the event of a suspected allergic reaction or anaphylaxis, as ordered by the student's healthcare provider.

Student Information Student Name: ______________________________________________ Date of Birth: _____________________ Grade: _____________ Known Allergies: ____________________________________________ Emergency Contact Name: ____________________________________ Emergency Contact Phone: ___________________________________

Healthcare Provider Authorization Diagnosis/Allergy: __________________________________________ EpiPen Dose: □ EpiPen Jr. (0.15 mg) □ EpiPen (0.3 mg) Benadryl Dose: _____________________________________________ Symptoms requiring EpiPen administration: ____________________________________________________________ ____________________________________________________________ Symptoms requiring Benadryl administration: ____________________________________________________________ ____________________________________________________________

Call 911 after EpiPen administration: □ Yes □ No Additional Instructions: ____________________________________ ____________________________________________________________ Healthcare Provider Name: __________________________________ Phone: ______________________ Fax: _________________________ Provider Signature: _____________________ Date: _____________

Parent/Guardian Permission I authorize Bishop Fenwick High School and its designated personnel to administer EpiPen and/or Benadryl to my child as prescribed above. I understand that emergency medical services may be activated when deemed necessary.

Parent/Guardian Name: __________________________________ Signature: ______________________________ Date: __________ Cell Phone: __________________ Secondary Phone: __________

School Nurse Authorization School Nurse Review: _____________________________________ RN Signature: __________________________ Date: ___________