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This form is to be completed and
submitted for students that require prescription
medication while at PCC. Both parent and licensed
prescriber’s sections must be
completed and submitted no later than May 30, 2007.
PARENT SECTION:
Student’s name
___________________________________________Date of Birth _______
Last
First
Middle Initial
I consent to have the PCC Nurse, or designee, administer the
medication prescribed by:
_____________________________________to__________________________________
(licensed prescriber’s name)
(student’s name)
I give the PCC nurse permission to
share information relevant to the prescribed medication
administration as she determines appropriate for my child’s health
and safety. I understand that
any medication that is not picked up by the close of the last day of
the PCC Program will be
destroyed.
________________________________________________________
____________
(parent/guardian’s signature)
(date)
I give my child permission to
self-administer his/her medication if the PCC nurse determines that
it is safe and appropriate: ____Yes ____ No
LICENSED PRESCRIBER SECTION:
Child’s name_____________________________________________ Date of
Birth _______
1. Medication_________________________Route of
Administration____________________
Dosage____________Frequency____________Time(s) of
Administration______________
Side effects or special
instructions _____________________________________________
Date of order____________Discontinuation
Date_________________________________
2. Medication_________________________Route of
Administration____________________
Dosage____________Frequency____________Time(s) of
Administration______________
Side effects or special
instructions _____________________________________________
Date of order____________Discontinuation
Date_________________________________
3. Medication_________________________Route of
Administration____________________
Dosage____________Frequency____________Time(s) of
Administration______________
Side effects or special
instructions _____________________________________________
Date of order____________Discontinuation
Date_________________________________
4. Medication_________________________Route of
Administration____________________
Dosage____________Frequency____________Time(s) of
Administration______________
Side effects or special
instructions _____________________________________________
Date of
order____________Discontinuation
Date_________________________________
Consent for self-administration provided the PCC nurse determines it
is safe and appropriate.
____Yes ____ No
________________________________________________________________________
(signature of licensed prescriber)
(date)
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