PART 1: PARENT OR LEGAL GUARDIAN TO COMPLETE

Student’s Name: ___________________________________    DOB: ______________________________
School: ___________________________________________    Grade: _____________________________
Parent or Legal Guardian Name (print): ______________________________________________________
Parent or Legal Guardian Signature: _____________________________ Date: ______________________
   (Please note: A parent/legal guardian consent form must also be filled out. Obtain from the school nurse)

PART 2 : LICENSED PRESCRIBER TO COMPLETE

1.	Relevant Diagnosis (es): _____________________________________________	ICD-10 Code________________
2.	Student’s General Health Status: ___________________________________________________________________
3.	Medication:	___________________ Strength of Medication:  ________ Dosage (amount to be given): _________

Route:	    By mouth            By inhalation	  Other _______    Frequency _________ Time of each dose _________

ALL PRN MEDICATION MUST DENOTE TIME INTERVAL BETWEEN DOSAGE
School medication orders shall be limited to medication that cannot be administered before or after school hours.
School nurse must approve special circumstances.

4.	Duration of medication order	:          Until end of school term	Other ___________________________
5.	Desired Effect: ________________________________________________________________________________
6.	Possible side effects of medication: _______________________________________________________________
7.	Any contraindications of administering medication: __________________________________________________
8.	Allergies to food or medicine include: _____________________________________________________________
9.	Other medications taken at home: ________________________________________________________________
10.	Next visit is: __________________________________________________________________________________

__________________________________________________ 	        ____________________________________ 
Licensed Prescriber's Name (Printed)                           		        NPI #
__________________________________________________	        ____________________________________
Address                             		Phone /Fax Numbers
__________________________________________________    _________________________    __________       _______________
Licensed Prescriber’s Signature                                                         Credentials (i.e., MD, NP, DDS)   APRN #                 Date 
Each medication order must be written on a separate order form. Any future changes in directions for medication ordered require new medication orders. Orders sent by fax are acceptable. The original orders should be mailed to the school within five (5) business days. Orders to discontinue also must be written.

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, insulin, epi-pen, or glucagon.
1.	Is the student a candidate for self- administration?		               Yes               No
2.	Is the student a candidate for self-care for after-school and off campus activities, which may include self-carry of emergency narcotic nasal medications?				Yes	  No
3.	Has this student been adequately instructed by you or your staff and demonstrated competency in self-administration 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?						Yes  	No
____________________________________________  _________________________  _____________ ____________
Licensed Prescriber’s Signature                                           Credentials (i.e., MD, NP, DDS)   APRN #                 Date