MASSACHUSETTS UNION NO. 31
and
SILVER LAKE REGIONAL SCHOOL DISTRICT
MEDICATION ORDER AND AUTHORIZATION FORM
Date_____________________________
PHYSICIAN’S ORDER
Name of Student_______________________________________ DOB ____________________
Grade and Teacher ______________________________________________________________
Medication ____________________________________________________________________
Dosage________________________________________________________________________
Route_________________________________________________________________________
Time to be Administered _________________________________________________________
Side Effects____________________________________________________________________
Date of Order ________________________ Discontinuation Date ________________________
Drug or Food Allergies___________________________________________________________
Physician’s Signature____________________________________________________________
Physician’s Address and Phone Number_____________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
PARENT/GUARDIAN AUTHORIZATION
I hereby request and authorize the School Nurse to give my child _________________________
the medication ordered above by his/her physician.
I also authorize the teacher of my child to dispense his/her medication during any field trips
during the school year.
Parent/Guardian Signature_______________________________ Date ____________________
Address _____________________________________________ Phone ___________________