Last Name: First Name: DOB: DateTeacher: Ext: Room: Grade:School: School year: Medication Name: Strength: Dose: Rote: Time: Indication if PRN: Best refill/contact route: Time needed for refill: Alternate schedule instructions: late/delayed arrivalearly altered/releaseSpecific Instructions:
Last Name: First Name: DOB: Date Medication Name and Dosage: Instructions, including TIME to give medication: Medication Type: Over the counter Prescription Controlled
For late/delayed arrival, please: give medication when arrives to clinic hold medication if arrives after contact me before giving medication For early/alternate dismissal, please: give medication at hold the medication contact me before giving medication I authorize clinic staff to administer the medication as described here. Medication(s) be stored in secure location in clinic. My authorization will be in effect until a termination or change in medication is submitted in writing or at the end of the school year. I agree to use my child’s patient portal to coordinate medication drop off in advance with the SBC staff. I understand all medications will be counted in with SBC staff and an adult school staff witness. All medications must be labeled. Prescription medications must have a valid pharmacy label. Medication(s) may only be labeled for one student. Any medication left in the clinic past the last day of school will be wasted/destroyed per Indiana state law. I give permission for my child to transport non-controlled medications to/from school in labeled container. I agree it is my responsibility to notify clinic staff of any changes immediately and in writing. This is to be done electronically through my child’s patient portal Notify me by:text email call when my child has doses left of their medication to allow adequate time to get a refill.
Signature: Signature Date: Date
Name: Daytime#: Relationship to student: Email: Email