Medication consent form 03-04

STUDENT NAME ______________________________________GRADE_____ ALLERGIES: _____________________________________________________ REACTION: ______________________________________________________ List ALL PRESCRIPTION medication your child takes on a regular basis both at home and school. Al medications must be delivered to school by a parent or The fol owing medications are available in the Health Room in generic form. Please place a check mark in the box next to each medication your child is authorized to receive from the OLGC Registered Nurses. Acetaminophen 325mg (generic for Tylenol) Ibuprofen 200mg (generic for Advil/Motrin) Sudafed PE 10mg (non- drowsy decongestant) Benadryl 25 mg (anti-histamine, allergies) Neosporin Ointment (antibiotic ointment) Hydrocortisone Cream 1% (anti-itch cream) I authorize the OLGC Registered Nurses to administer the above selected medications as specified by the manufacturer of the “over-the-counter” product or as directed by the prescribing physician. This form must be on file for the authorized administration of OTC medications as outlined in the Guidelines for Use of Protocols for School Nursing Practice. I agree to abide by the Our Lady of Good Counsel Medication Policy found on the back of this form and in the on line Parent/Student Handbook. PARENT SIGNATURE __________________________________DATE_______ THIS INFORMATION IS ALSO AVAILABLE ON OLGC WEBSITE • The Maryland State School Medication Administration Authorization Form is available on the school website. If your child is on a prescription medication, please have your physician fil out the authorization form for each prescription medication your child wil be taking at school. • Medications must be delivered to the school by the parent/guardian in the original prescription container, with the pharmacist’s label attached. If the medicine is an over –the –counter medication, it must be unopened and delivered in the manufacturer’s original packaging. • Students are NEVER permitted to carry any medications other than prescribed emergency medicines. (Inhalers for asthma or Epi-pens for • Students are NEVER permitted to return to school on narcotic medication for pain management. These medications may cause dizziness, light- headedness, sedation, as wel as other symptoms which make it unsafe for them to be in school. If the pain is severe enough to require a narcotic, • Over the Counter medications are available in the Health Room for those students who have a current Medication Consent form on file. The Medication Consent form is required every year for every student and is • Any change in dosage of a prescription medication must be authorized in • The parent/guardian is responsible for col ecting any unused portion of medication within one week after expiration of the physician’s order and /or the end of the school year. Medications not claimed at that time wil be • Please notify the Nurse in writing if your child has had a change in his/her

Source: http://www.olgchs.org/uploaded/Health_Room/2013-2014/Med_Consent_13-14.pdf