BFHS_Medication_Form_with_Logo

Bishop Fenwick High School School Medication Administration Authorization Form – Prescribed by MD This order is valid only for school year (current): ______________________________ This form must be completed fully for the school nurse to administer the required medication. A new medication administration form must be completed at the beginning of each school year, for each medication, and each time there is a change in dosage or time of administration of the medication.   

Prescription medication must be in a container labeled by the pharmacist.

An adult must bring the medication to the nurse’s office.

NO more than a 30-day supply may be kept in the nurse’s office.

Prescriber Authorization Name of Student: _____________________________ DOB: __________ Grade: ______ Medication Allergies: ________________________________________________________ Condition for which medication is being administered: ___________________________ Medication Name: _________________ Dose: _________ Route: _________________ Time/Frequency of Administration: ________ If PRN(as needed), Frequency: __________ If PRN, for what symptoms: _________________________________________________ Relevant side effects: □ None expected □ Specify: ___________________________ Medication shall be administered from: _____________ to _____________ Prescriber Name/Title: _______________________________________________________ Telephone: ___________________ Fax: ____________________ Address: _________________________________________________________________

Prescriber Signature: ______________________________ Date: _________________ Parent/Guardian Authorization I request designated school personnel to administer the medication as prescribed by the above prescriber. I certify that I have legal authority to consent to medical treatment for the student named above, including the administration of medication at school. I understand that at the end of the school year, an adult must pick up the medication; otherwise, it will be discarded. I authorize the school nurse to communicate with the health care provider as allowed by HIPAA. Parent/Guardian Signature: _____________________________ Date: _____________ Home Phone: __________________ Cell Phone: __________________ Work Phone: __________________ Self Carry / Self Administration of Medication Prescriber Authorization: ______________________________ Date: _____________ School RN Approval: __________________________________ Date: _____________