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MEDICATION REQUEST FORM
(Please print/copy this form as needed.) 

To be completed by physician:

Student's name:    ___________________________________________________________________

 

Reason for medication:   ______________________________________________________________

 

Precautions/adverse reactions:   ________________________________________________________

 

Medication, dosage, times to be given:   __________________________________________________

 

___________________________________________________________________________________

 

Date:  ____________________                      Physician Signature:   ________________________________

 

                                                            Physician Phone Number:  ________________________________

 

 

To be completed by parent/guardian:

 

I request that my child be given the medication as directed above.  I will bring the medicine to school and pick up any unused doses, or it will be discarded.  I will notify the school immediately if the medication order is changed or cancelled.

 

Date:  _____________________                   Parent/Guardian Signature:  ___________________________