MEDICATION ORDER
(To be completed by a Licensed Prescriber: Physician, Nurse Practitioner or others authorized by Chapter 94C)
Name of Student ____________________________________________Date of Birth_____________________
Address __________________________________________________________________Grade ___________
Name of Licensed Prescriber (Print) __________________________ Prescriber 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)
Date of Order ______________________________ Discontinuation Date ___________________________
Specific directions or information for administration_________________________________________________
_________________________________________________________________________________________
Special side effects, contraindications, or possible adverse reactions to be observed__________________________
_________________________________________________________________________________________
Diagnosis (if not in violation of confidentiality)______________________________________________________
Any other medical conditions (if not in violation of confidentiality) _______________________________________
Other medication being taken by the student_______________________________________________________
_________________________________________________________________________________________
Date of the next scheduled visit or when advised to return to prescriber __________________________________
_______________________________________ _________________________
Prescriber Signature Date
Erving School Union #28 assures that all programs, activities and employment opportunities are offered without regard to race, color, sex, age, creed, homelessness, religion, national origin, sexual orientation and disability.