PrescrCELLAion Medication

Physician's Order and Parental Consent

The medication policy of the Chester County School System states that medications be administered only when the student's health requires that they be given during school hours.  Medications administered at school must be in original container with pharmacy label attached and administered under the supervision of the school nurse, school administrator, or his/her designee.  Written authorization from the student's parent/guardian and physician is required, and is for the current school year only.

Student's Name:  ________________________          Date: _____________

Physician's Section

The above named student is to receive:

Medication Name:  ____________________

Dosage & Route of Medication: _____________________________

Time(s) medication is to be taken at school:  ___________

Diagnosis:_______________________________

Date of termination of this medication: ________________________

Possible side effects and/or other special instructions:  ____________________________________________________________

____________________________________________________________

Date:  ___________   Physician Signature:  ___________________________

(Please Print)               Physician Name:  ______________________________

                                    Address:              ______________________________

                                                                ______________________________

                                    Phone Number:    _______________________________

The undersigned assumes full responsibility for any side effects or complications his/her child may have as a result of taking this medication, and is responsible for informing the school of any changes in treatment.  Physician's orders must accompany any medication changes.

I hereby give permission for my child to take the above medication.

Parent/Guardian Signature:   ___________________________   Date: __________

Home Phone:  _________________       Work Phone:  _______________

Emergency Phone:  _____________