3416F Form - Physician's Orders for Medication at School

FPS Logo
Health Services
315 129th Street South Tacoma, WA 98444
Physician’s Orders for Medication at School
Patient:                                                                                            Date of Birth:                                      
Medication should be given to a student at school only when absolutely necessary. Whenever possible, the parent and physician are urged to design a schedule for giving medication outside of school hours. If this is not possible, it must be understood by the parent that the Health Room Assistant will dispense the medication. The principal will designate the person responsible to dispense medication on an individual basis. The school accepts no responsibility for untoward reactions when the medication is dispensed in accordance with the physician’s directions.
Is it necessary to dispense this medication during school hours? Yes No
If yes, please give diagnosis or reason:                                                                                        
Drugs and dosage form:                                                                                                                            
Dose and mode of administration:                                                                                                               
Time(s) to be given:           Lunch            Hour                                       
Duration without subsequent order:         Weeks                School Year
Side effects of drug (if any) to be expected:                                                                                                
Medication to be carried by student:           Yes             No
Physician Signature:                                                    Print or Stamp Name:                                             
Date:                                             Phone:                                                                                                
Parent’s Permission
I request that the school nurse, principal, or a staff member designated by him/her be permitted to dispense to my child (name of child)                                                                        , the medication prescribed by (name
of physician)                                                                  , for a period from                     to                    .
*  The medication to be furnished is to be brought in by me in the original container labeled by the pharmacy or physician with the child’s name, name of the medicine, the amount to be taken, the time of day to be taken, and the physician’s name.
*  I understand that my signature indicates my understanding that the school accepts no liability for untoward reactions when the medication is administered in accordance with the physician’s directions.
*  This authorization is good for the current school year only.
*   In case of necessity, the school district may discontinue administration of the medication with proper advance notice. If notified by school personnel that medication remains after the course of treatment, I will collect the medication from the school or understand that it will be destroyed.
*  I am the parent or legal guardian of the child named.
Signature of Parent/Guardian:                                                                                 Date:                         
Parent’s Home Phone:                             Work Phone:                                      Cell Phone: