MEDICAL PRACTITIONER
ORDER FORM
MEDICATION GIVEN AT
SCHOOL
NAME ____________________________ GRADE ______ DATE ___________
The school nurse at
this form as ordered by my child’s
medical practitioner.
PARENT/GUARDIAN SIGNATURE __________________________________
TO BE COMPLETED
BY MEDICAL PRACTITIONER – (Refer to guidelines on reverse side).
MEDICATION___________________DIAGNOSIS ______________________
DOSAGE _________________ ROUTE _________ FREQUENCY __________
ADDITIONAL INSTRUCTIONS ______________________________________
__________________________________________________________________
Must medication be given on school half-days? Yes ____ No ____
Must medication be given during field trips? Yes ____ No ____
IF
MEDICATION IS AN INHALER, EPIPEN, AND/OR INSULIN PEN OR
PUMP – REFER TO
SELF-ADMINISTRATION FORM.
MEDICAL PRACTITIONER SIGNATURE _____________________________
PRINT OR STAMP NAME & ADDRESS HERE:
Sincerely,
Mrs. Lynch
Mrs. Kelly Lynch, R.N., B.S.N.
Certified School Nurse/Health Teacher