Doctor Prescription Template - Free Download
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Doctor Prescription Template
Doctor Prescription Template
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Dear Parents/Guardians,
To comply with school policy, all medication is to be administered by school personnel
and MUST be pre-approved. Please complete and sign request for administration of
medication on reverse side. This form needs to completed, signed and on file at the
school before any medication can be administered. Students may NOT keep
medication with them unless they have been designated self managers (certified and
authorized to self medicate) and cleared by the principal to do so. All medicine
(including inhalers) must be secured in the classroom or school office before requesting
that medicine be administered at school.
The medication must be brought to school as follows:
DO NOT SEND medication in baggies or tupperware.
Prescription medications must be in the container labeled by the pharmacist.
Labels must include student name, name of medication, dose, time interval.
Over the counter medications must be in original container or box.
Important steps to follow:
1. A doctorʼs signature is necessary for the following treatment: epi-pens, bee sting kits,
and inhalers. This can be on doctor letterhead or from a prescription pad. Please attach
to this form.
2. Parent/Guardian signature is required for all over the counter medications (tylenol,
cough medicine, etc.) including naturopathic medicine. (see reverse side)
All medication MUST be given under adult supervision. This is for the safety of your
child and others. If you have any questions, please contact the Ivy School.
I have read and understand these instructions.
Parent/Guardian Signature
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