Sample Medication Order Form
(to be completed by a licensed prescriber)

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

* if not in violation of confidentiality.