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(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:  ___________________________