Permission Form For Prescribed / Overcounter Medication

St. Margaret Mary

813 Shelbyville Rd.

Louisville, KY  40222

Phone 426-2635   Fax 426-1304

Date form received by school:                                       

Student:                                                                         Age:                           

Grade:                                      Teacher:                                                          

To be completed by the physician or authorized prescriber.

Reason for medication:                                                             

Name of medicine:                                                                               

Form of medication / treatment:

£  Tablet/ capsule        £  Liquid   £  Inhaler   £  Nebulizer   £  Other                                    

Instructions (Schedule and dose to be given at school):                                                                                                                                                                                                    

Start:    *  date form received                          Other date:                                                         

Stop:    *  end of school                                   Other date / duration:                              

*    for episodic / emergency events only

Restrictions and /or important effects:    *  None anticipated

*   Yes.  Please describe:                                                                                                                                                                                                                                                         

Special Storage Requirements:  *  None     *  Yes                                                                                                                                                                                                                    

Additional Instructions:                                                                                                                                                                                                                                                  

Date:                                                          Signature:                                                               

Physician’s Name:                                                                                            

Address:                                                                                                          

Phone #:                                                                                                          

Doctor’s Signature:                                                                                           

To the school:  Please report concerns about medications or disease to the above physician.

To be completed by parent/guardian:

I give permission for                                                      (name of child)   to receive the above medication at school according to standard school policy.  (School requires parent/guardian to bring the medication in its original container.)

Date:                            Signature:                                              Relationship:                             

Parent/Guardian Phone Numbers:  Home                        Work                 Cell