Get Medication Administration Form Pdf 2016-2024

Request for Administration of Medication In Hampton Roads Schools This form is accepted by all public schools in Chesapeake Norfolk Portsmouth Suffolk and Virginia Beach NOTICE TO PARENTS The parent/legal guardian must bring medication to school in a container that is appropriately labeled by the pharmacy or physician. Today s Date Name of Student Last First MI School Student Attends Student s Date of Birth Mo/Day/Yr Student s Diagnosis Medication Dosage Time of Administration Route of Administration and Instructions Start Date End Date Diagnostic ICD-9 Code For Norfolk Public Schools Only Physician/Nurse Practitioner/Physician s Assistant/Dentist s Name please print Phone Number PARENT/LEGAL GUARDIAN I hereby give permission for the school to administer the medication as prescribed above. I also give permission for the school to contact the above health care provider regarding the administration of this medication* Signature Parent/Legal Guardian Date GUIDELINES FOR PRESCRIBING MEDICATIONS TO BE ADMINISTERED TO STUDENTS DURING THE SCHOOL DAY We welcome your support in providing services to our students. When prescribing medications for school age children kindly consider the following requests and policies Whenever possible avoid prescribing medication for administration during school hours especially medications to be administered for a short period of time. Schools are required to have appropriately labeled pharmacy/physician containers. These will be kept under lock and key in the school clinics. Carrying of inhalers on the person is discouraged unless ordered by the physician because such items are easily stolen lost or forgotten at home leaving the student in a dilemma and possibly in a medical crisis. Any change of prescription requires a new written order from the prescribing physician* Students are not allowed to transport medication on their person to and from school* Thank you for helping us provide the best possible services for students taking medications. HAMPTON ROADS PUBLIC SCHOOLS STUDENT HEALTH SERVICES SUPERVISORS Revised August 2016 THIS FORM MAY BE REPRODUCED AS NEEDED. I also give permission for the school to contact the above health care provider regarding the administration of this medication* Signature Parent/Legal Guardian Date GUIDELINES FOR PRESCRIBING MEDICATIONS TO BE ADMINISTERED TO STUDENTS DURING THE SCHOOL DAY We welcome your support in providing services to our students. When prescribing medications for school age children kindly consider the following requests and policies Whenever possible avoid prescribing medication for administration during school hours especially medications to be administered for a short period of time. When prescribing medications for school age children kindly consider the following requests and policies Whenever possible avoid prescribing medication for administration during school hours especially medications to be administered for a short period of time. Schools are required to have appropriately labeled pharmacy/physician containers. These will be kept under lock and key in the school clinics. .