PLANO
INDEPENDENT SCHOOL DISTRICT |
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Medication
Request Form |
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| ________________ ________________
______________ _____________ _____________ |
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LAST NAME |
FIRST NAME |
GRADE |
DRUG |
ALLERGIES |
|
| Please follow the guidelines below when bringing
medication to school: 1. For student safety, all medications should be brought to the clinic by the parent. Medications are not provided by the school. 2. All medication must be in its original, properly labeled container with a written request signed by the parent/guardian. 3. Only medication that cannot be given at home will be given at school. 4. Only a 30-day supply of medication will be accepted at a time. (Amount received by nurse________) 5. Medication that has expired or is not picked up by the parent will be destroyed. 6. Authorized district employees may administer medication in the absence of the nurse. |
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| Medication Dosage_____________________________Time/Days to Give_______________________ | |||||
| Prescription Number _________ Will this be the first dose of a new medication for your child? ? YES ? NO | |||||
| What is the condition for which this medication is required? __________________________________ | |||||
| Any special instructions/precautions/side effects of this medication for your child?___________________ | |||||
| Parent Signature ________________________ Date ___________ Phone Number ____________________ | |||||
| Physician’s Name _______________________________________Phone Number __________________ | |||||
| A physician’s signature is required to keep or administer over-the-counter medication for more than 10 days from the original parent request. | |||||
| Physician’s Signature ____________________________________ Date ___________________________ | |||||