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ERVING SCHOOL UNION #28
ERVING, LEVERETT, NEW SALEM, WENDELL, SHUTESBURY
18 PLEASANT STREET
ERVING, MA 01344
413 423-3337
FAX 413 423-3236

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 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.