Marshall County Schools Health Services
AUTHORIZATION TO DESPENSE MEDICATION

Child's Name:_________________________________________________________

Name of Medication:____________________________________________________

Physician Prescribing: _____________________________________________________

Telephone Number of Physician: __________________________________________

Time(s) to be Administered: ________________________________________________

Dosage: ______________________________________________________________

Possible Side Effects, if known:____________________________________________

History of Drug or Food Allergies:___________________________________________

Termination Date for Medication: __________________________________________

_____________________________________________________	________________
Signature of Parent or Guardian	Date
______________________________________________________	________________
Signature of Physician	Date

*Physician's signature required for all prescription medications dispensed in school. These medications include inhalers, breathing treatments, over the counter medications, creams, ointments, antibiotics, and prescription drugs.

BE SURE THAT.....
*All medicines are in original labeled container.
*Medicines are brought to school by an adult.
*All forms completed and signed.

MEDS WILL NOT BE GIVEN IF......
*Brought to nurse/school by student.
*Delivered in baggies, envelopes, or other inappropriate container.
*Forms not completed with MD and Parent Signature and contace number.

FOR USE OF INHALERS
Check one

Keep with child___________

Keep in clinic____________