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Medication Order Form #410 - Federal Way Public Schools

Medication Order Form #410 - Federal Way Public Schools

Medication Order Form #410 - Federal Way Public

FEDERAL WAY PUBLIC SCHOOLS MEDICATION ORDER FORM - Authorization for Administration of Medication at School Student Name: DOB: Student ID: School: Grade: THIS PORTION TO BE COMPLETED BY THE LICENSED HEALTH CARE PROVIDER Name of Medication: Diagnosis Dosage & Route Time Specific Instructions and/or side effects to be expected: _______________________ _________________ _________________ __________ _______________________ _________________ _________________ __________ _______________________ _________________ _________________ __________ If given ‘as needed’ specify length of time between doses: Emergency procedure in case of serious side effects: ________Yes _______No - Licensed Health Care Provider/designee has instructed student on correct use of inhaler or medication. ________Yes _______No - Student has demonstrated to health care provider/designee necessary skills to administer life saving medication by self and student can carry medication. I request and authorize that the above-named student be administered the above identified medication in accordance with the instructions indicated above from (date) through (date) not to exceed current school year as there exists a valid health reason which makes administration of the medication advisable during school hours. Health Care Provider’s Signature: Date: Print Name: Phone Fax Please note: MEDICATION MUST BE PROVIDED BY THE PARENTS IN THE ORIGINAL CONTAINER WITH INSTRUCTIONS. If samples of medication are to be given, they must be labeled with the name of the student, dosage, and time to be given. Form #410 Rev. 4/12 page 1

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