Shalom School-Based Clinic Medication

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

Shalom School-Based Clinic Medication Consent (Clinic documentation section)

Shalom School-Based Clinic Medication Consent (Parent/Guardian Section)