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Medication Record Form
11/29/2012

BRISTOL TENNESSEE CITY SCHOOLS

MEDICATION RECORD

 

To be completed by physician

NAME ____________________________ SCHOOL/TEACHER __________

NAME/TYPE OF MEDICATION ____________________________________

PURPOSE OF MEDICATION ______________________________________

START DATE ______________________   END DATE ________________

DOSAGE and OTHER INSTRUCTIONS _______________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

POSSIBLE SIDE EFFECTS/REACTIONS _____________________________

_________________________________________________________

 

______________________________     _______________________

     PHYSICIAN’S NAME (print or type)             PHYSICIAN’S SIGNATURE

 

I authorize the principal and/or designee to administer the medication to my child as stated above. I release the school personnel from any and all liabilities.

 

______________________________ ______________

                            Parent Signature                                                                  Date

PARENT PHONE NUMBERS DURING SCHOOL DAY: ______________________

 

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MEDICATION LOG

DATE

TIME

INITIALS

DATE

TIME

INITIALS