Parental Consent for Medication Administration to their Child

Date:_______________                        School:__________________________

Student:___________________________________   Grade:_____________

My child is to receive_____________________________ medication according to the physician's directions given for_____________________. This treatment will last ____________________. I give my permission for this medication to be dispensed to my child at school. The school has my permission to call the physician with any questions regarding the medication. My child has____________________ drug allergies.

Signature:_________________________________________________

Relationship to student: ______________________________________

----------------------------------------------------------------------------------------------------------------

Physician Consent for Medication Administration

Date: _______________________   Name of Student: ________________________

Medication: __________________________________  Dose: __________________

Time Interval: _______________________________________________________________________________________

Diagnosis or reason for treatment: ________________________________________________________________________

Side Effects to look for: ________________________________________________________________________________

                                   ________________________________________________________________________________

Restrictions: _________________________________________________________________________________________

Signature: _______________________________________________