Marshall County Schools Health Services
INHALER AUTHORIZATION

Child's Name ________________________________________________

Type of Inhaler ______________________________________________

Name of Physician ___________________________________________

Telephone Number of Physician _________________________________

Time to be Administered _____________________________________________

Dosage ______________________________________________________________

Possible Side Effects ___________________________________________________

Termination Date for Medication __________________________________________

Do you want child to have inhaler with them at school or have it locked in school
clinic?

Child Should Keep _______________ Locked in Clinic _______________________

________________________________________________	___________________
Parent/Guardian Signature	Date
________________________________________________	___________________
Physician Signature	Date

**Physician's signature required for all prescription medications and any other medication that is given for five or more days.

**PLEASE FILL OUT FORM COMPLETELY AND RETURN TO SCHOOL.