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

    Shalom School-Based Clinic Medication Consent (Clinic documentation section)
  • Last Name: * First Name: * DOB: Pick a Date
    Teacher: Ext: Room:
    Grade:School: School year:
    Medication Name: Strength: Dose:
    Route: Time: Indication if PRN:
    Best refill/contact route: Time needed for refill:
    Alternate schedule instructions:  

    Specific Instructions:

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

    Shalom School-Based Clinic Medication Consent (Parent/Guardian Section)
  • Last Name: * First Name: *
    DOB: Pick a Date Medication Name and Dosage:
    Instructions, including TIME to give medication:
    Medication Type:         

  • For late/delayed arrival, please: 
           
    For early/alternate dismissal, please:
          
    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:       doses left of their medication to allow adequate time to get a refill.

  • Signature:    Date: Pick a Date   

  • Name: Daytime#:
    Relationship to student: Email:

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  • Should be Empty: