Saint Agnes School
Health Office
(781) 641-6047

Prescription Medication Form

THIS FORM IS TO BE COMPLETED BY THE PHYSICIAN PRESCRIBING THE MEDICATION.

Name of Student: ______________________________________________________________

Name of Licensed Prescriber: _____________________________________________________
Address: _______________________________ Telephone Number: ______________________

*Diagnosis: ___________________________________________________________________

Medication: ___________________________________________________________________
(A separate form is needed for each medication prescribed and needed during the school day.)

Route of Administration: _______________________ Dosage: __________________________

Frequency: _________________________ Time(s) of Administration _____________________
(Please note:  Whenever possible, medication administration should be scheduled at times other than school hours.)

Start Date: _________________________ End Date: __________________________________

Possible Side effects or Adverse Reactions: __________________________________________

Any Special  Instructions or Considerations: _________________________________________

*Any other medical conditions or Allergies: _________________________________________

*Any Other Medications Being Taken by Student: ____________________________________

Next Scheduled Physician's Visit or Follow-up Visit: __________________________________

Consent for self administration (for inhaler and epi-pen use only) provided the school nurse 
determines it is safe and appropriate.  YES ____ NO ____

___________________________________            ______________
Signature of Licensed Prescriber                                    Date

*If not in violation of confidentiality.