Physician's Request for the Administration of Medication by Mettle Personnel

Physician’s Request for the Administration of Medication by Mettle Personnel

No medication that is prescribed by physician for a student shall be administered to that student unless:

The designated personl receives a written request, signed by the parent, guardian, or other person having care or charge of the student, that the drug be administered to the student.
The signed statement that is presented to the designated person shall include the following information:

Name of Student(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

The student listed above is under my care and should receive the following drug/dosage(Required)

The following times(Required)

Specific instructions for administration (if any)(Required)

Common or usual side effects to watch for (if any)(Required)

The date the administration of the drug is to begin(Required)

Physician's Signature(Required)

Phone numberr where the physician can be reached if emergency(Required)