Medication Form

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Contact us
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Medication FormWCCMW2023-12-17T09:52:29-05:00

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PART 1: PARENT OR LEGAL GUARDIAN TO COMPLETE.

Student’s Name

School

Parent or Legal Guardian Name (print):

Parent or Legal Guardian Signature:

BirthDate

Grade

Date

PART 2: LICENSED PRESCRIBER TO COMPLETE.

Relevant Diagnosis(es):

Student’s General Health Status:

Medication:

Strength of medication:

Dosage (amount to be given):

Check Route:

Checkboxes

By mouth
By inhalation
Other

other

Frequency

Time of each dose

Duration of medication order:

Checkboxes

Until end of school term
Other

Other Duration

Desired Effect:

Possible side-effects of medication:

Any contraindications for administering medication:

Other medications being taken by student when not at school:

Next visit is:

Prescriber’s Name (Printed)

Prescriber’s Signature

Address

Credential (i.e., MD, NP, DDS)

Phone and Fax Numbers

Date

PART 3: LICENSED PRESCRIBER TO COMPLETE AS APPROPRIATE.

Inhalants / Emergency Drugs
Release Form for Students to be Allowed to Carry Medication on His/Her Person

Use this space only for students who will self-administer medication such as asthma inhaler.

Is the student a candidate for self-administration training?

Has this student been adequately instructed by you or your staff and demonstrated competence in selfadministration of medication to the degree that he/she may self-administer his/her medication at school, provided that the school nurse has determined it is safe and appropriate for this student in his/her particular school setting?

If training has not occurred, may the school nurse conduct a training program?

Licensed Provider’s Signature

Date

Title

988 Suicide and Crisis Lifeline

988lifeline

VISIT US

7591 Fern Ave. Suite 1705

Shreveport, LA 71105

Email Us: contactus@wccmw.com

CALL

Tel: 318-550-3398

Fax: 318-550-3481

SOCIAL MEDIA

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Disclaimer:

For informational purposes only. Always seek advice from a medical professional. In case of emergency, please call 911 or go to the nearest emergency room

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