MASCONOMET REGIONAL SCHOOL
DISTRICT HEALTH OFFICE
Medication Order
(to be completed by a licensed prescriber)
Name of
Student___________________________________________ Date of Birth ___________
Address___________________________________________________ Grade ___________
(street) (city/town)
Name of Licensed
Prescriber__________________________________ Title___________________
Business
Phone_________________________
Emergency Phone__________________________
Medication________________________________________________________________________
Route of
administration____________________________________ Dosage___________________
Frequency_____________________Time(s)
of Administration______________________________
(Please note: Whenever
possible, medication should be scheduled at times other than school hours).
Specific directions or
information for administration:_______________________________________
Date of
Order___________________ Discontinuation
Date__________________________________
Diagnosis*_________________________________________________________________________
Any other medical
condition(s)*________________________________________________________
Optional Information
1.
Special
side effects, contraindications, or possible adverse reactions to be
observed:_______________________________________________________________________
2. Other medication being taken by the
student:___________________________________________
_______________________________________________________________________________
3. The date of the next scheduled visit or when advised to return to
prescriber: __________________
4. Consent for self-administration (provided the school nurse
determines it is safe and appropriate).
Yes_____ No_____
_____________________________________
Signature of Licensed Prescriber
* if not in violation of
confidentiality.