CONCORD PUBLIC SCHOOLS
CONCORD-CARLISLE REGIONAL HIGH SCHOOL
MEDICATION
ORDER FORM
(TO BE
COMPLETED BY A LICENSED PRESCRIBER)
Name
of Student____________________________ Date
of Birth____________
Address________________________________________
Grade____________
(street) (city/town)
Name
of Licensed Prescriber________________________ Title____________________
Business
Telephone Number ________________________
Emergency
Telephone Number_______________________
Medication_______________________________________________________________
Route
of Administration__________________________ Dosage_________________
Frequency_____________________________ Time(s) of administration__________
(Please note: Whenever
possible, medication should be scheduled at times other than school hours)
Specific
directions or information for administration________________________________
Date
of Order________________________ Discontinuation
Date:____________
Diagnosis*_______________________________________________________________
Any
other medical condition(s)*_______________________________________________
Optional
Information
_____________________________________________________________________
_____________________________________________________________________
Yes_______ No_______
__________________________________
Signature of Licensed Prescriber
__________________________
Date
*If not in violation of
confidentiality