CARROLLTON-FARMERS BRANCH I.S.D.
MEDICATION ORDERS AND PARENT
AUTHORIZATION
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Name:
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School: _________________ |
Grade: ______ |
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School Phone: |
Fax: |
Nurse: |
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Condition for which medication is to be given at school and administration instructions:
List all medications
or therapies to be used for this condition. Use
an additional form for other conditions
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Medication |
Route |
Dose |
Times |
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2. |
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4. |
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Physician Signature __________________________ Print Name: ________________________________
Telephone number: ____________________ FAX: _________________ Date: _____________________
Valid for this school year only. Non-prescription medication cannot be given as need or after 5 school days without a physician’s order.
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I request and authorize the Carrollton-Farmers Branch I.S.D. to administer the above medication as prescribed. I understand that the school administrator may designate any qualified person or persons to administer this medication per Texas Education Code, Section 22.052.
After 5 school days (5) students on non-prescription medications will be required to submit a physician’s authorization for continuance of medication. At no time will a non-prescription medication be given on an as needed basis without a physician authorization.
I also authorize the school’s registered nurse to consult with the prescribing physician to clarify this medication order, or in the interest of the student’s health, to discuss his/her response to the prescribed medication as required by Texas Nurse Practice Act.
PARENT/LEGAL GUARDIAN SIGNATURE: _______________________________________________
DAY TELEPHONE (S): _________________________________________ DATE: __________________
PAGER/MOBILE NUMER: ______________________________________________________________