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Medication Order Form
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.