Delphos City Schools

Physician's Medication Instructions For Prescription Drugs

1. Student's Name___________________________________________________________________

2. Student's Address_________________________________________________________________

3. School__________________________________________ 

4.Class_______________________________

5. Name of Drug___________________________________________________________________

6. Dosage of Drug___________________________________________________________________

7. Time or Intervals Dosage of Drug is to be Administered___________________________________________

8. Date Administration of Drug is to Begin_______________________________________________________

9. Date Administration of Drug is to Cease______________________________________________________

10. Severe Adverse Reactions that should be reported to the Physician_______________________________________________________________________________________________________________________

11. Physician Emergency Telephone Numbers___________________________________________________

12. Special Instructions for Administration of the Drug, including sterile conditions and storage____________________________________________________________________________________________________

13. Other Medication or Drugs Student is taking___________________________________________________________________________________________________________________________________

For Asthma Inhalers (fill out information above) If Inhaler must be kept with student. Doctor must state this and also fill out 14 and 15

14. Procedures to follow if medication does not relieve asthma attack______________________________________________________________________________________________________________________

15. Severe reactions that may occur if inhaler is used by a child for whom it is not prescribed____________________________________________________________________________________________________

I Understand that the school will not independently verify the propriety of the above instrustion.

                            _______________________                                   ____________________________

                                                   Date                                                           Physician's Signature

Delphos City Schools

Parent's Request for Administration of Prescription Drugs at School

1. Student's Name__________________________________________________________________________________________

2. Student's Address________________________________________________________________________________________

3. School_______________________________________________________ 

4. Class____________________________________

 I am the parent or legal guardian of the above named student.

I request that medication be administered at school to my child.

A physician's statement of instructions is attached.

I agree to submit a revised physician's statement signed by the physician who

prescribed the drug, if any of the original information changes.

 __________________    My child has permission to administer his or her own medication.

  __________________   I wish for the school to administer the medication to my child.

                        Emergency Telephone number for parent or legal guardian

                          _______________________________________________

_______________________              _____________________________________

                                                                           Date                                           Physician's Signature