LEWISVILLE ISD HEALTH SERVICES

MEDICATION ORDERS, PARENT AUTHORIZATION and CONSENT

Name: ______________________ School __________________ Teacher/Grade ____________

School Phone ______________ Fax ___________________ School Nurse _________________

Condition for which medication is to be given at school and administration instructions: ______

_____________________________________________________________________________

List all medications or therapies to be given at school for this condition. Use an additional form for other conditions

Medication Route Dose Times or Indications for Use

1.____________________ ____________ ____________ ______________________________

2. ___________________ ____________ _____________ ______________________________

3. ___________________ ____________ _____________ ______________________________

4. ___________________ ____________ _____________ ______________________________

Physician/Dentist Signature __________________________ Print Name ___________________

Office Number: ______________________ Fax Number: __________________ Date: _______

Valid for one school year. Physician/Dentist must be licensed to practice in Texas. Temporary (two months) orders from out-of-state US Physicians and Dentists are acceptable to initiate treatment for transferring students. A signature is required for controlled substances, daily or PRN therapy lasting over 15 days, or changes in the original prescription or order. A 15 day grace period is allowed for required physician or dentist orders and signatures.

I request and authorize the Lewisville ISD to administer the above medication as prescribed. I understand that the school administrator may designate any qualified person or persons to administer this medication. I also understand that although a reasonable attempt will be made to remind the student, it is expected that the student will be responsible in most situations for remembering to visit the healthroom for his medicine. Medication doses that could reasonably be taken at home will not usually be administered at school.

Non-prescribed, over-the-counter medications may be given for one school week and cannot be renewed without a prescription. A written parent request and full information is mandatory for each medication.

I also authorize the school’s registered nurse and the prescribing physician (printed name of physician) ________________________ to discuss this medication order, to clarify this medication order, or in the interest of this student’s health (printed name of student) ______________________, to discuss his/her response to the prescribed medication as required by Nurse Practice Act and Medical Practice Acts of Texas. It is expected that the school nurse will first attempt to notify a parent/guardian should such a contact become necessary. If the consent for the nurse and the doctor to consult re. this medication order is not granted or is revoked, it may not be possible for school personnel to administer the prescribed medications.

PARENT/LEGAL GUARDIAN SIGNATURE __________________________________________________

DAY TELEPHONE (S) ___________________ PAGER__________________ DATE __________________