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Mineral County Schools 36 Baker Place, Keyser, WV 26726            Phone: 304-788-4200            Fax: 304-788-4204

Physician Medicine Administration Form

Physician Medicine Administration Form

MINERAL COUNTY SCHOOLS HEALTH SERVICES
One Baker Place

Nancy Starcher, RN 788-4200

Trina Melody, RN 788-4213

Sharon Clark, RN 788-4216

Jennifer Cole, RN 726-4339 Roberta Jones, RN 788-4216

Keyser, West Virginia 26726

304-788-4200



Michael D. Burke, Director

Rob Woy, Assistant








Date:_______________________________









Dear Parent:



State guidelines require the school to have a completed “Medication Form” for each child who takes any medication at school. This must be completed before any medication will be administered. If any changes occur in medication or dosage, a new form must be completed. Again, no medication will be given without this form completed and submitted to the school nurse.

Please have your physician complete the back of this form completely. After you have signed the parent’s signature line, please return it to school.



Thank you,





Mineral County School Nurse



Medication noted on emergency medical form:______________________________________



(See Back)

Student_______________________________ School/Grade________________________
Birthdate______________________________ Allergies____________________________





This is to be completed entirely before any medication will be administered. The physician must complete and sign the form. If any changes occur in the medication or dosage, a new form must be completed. Only one medication per form please.




USE ONE FORM FOR EACH MEDICATION




Diagnosis_____________________________________________________________________



Name of Medication____________________________________________________________



Dosage_______________________________________________________________________



Frequency of Administration____________________________________________________



Route of Administration________________________________________________________



Intended effect of Medication____________________________________________________



Comments/Side Effects: ________________________________________________________ ________________________________________________________________________

________________________________________________________________________



May student self administer medication? _____ Yes _____ No



Student may self administer the following medication (circle): Epipen Inhaler Insulin





Physician’s Name______________________________________________________________



Physician’s Signature___________________________________________________________



Date_______________________________ Phone Number_______________________





I hereby give my permission for ____________________________________________ to take _____________ ____________________________________ at school as ordered by the physician. I understand that it is my responsibility to provide this medication. I further understand that any school nurse or employee who administers this drug to my child, in accordance with written instructions from the physician, shall not be liable for damages as a result of an adverse drug reaction suffered by my child due to the administration of the drug.



I understand that the medication must be brought to school in the original container appropriately labeled.



________________________________________________ __________________________________

Signature of Parent Date



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MINERAL COUNTY SCHOOLS: 36 Baker Place, Keyser, WV. 26726      |      Phone: 304-788-4200      |      Fax: 304-788-4204
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