Medical Consent Form


Student Name:

Date of Birth:

Age:


Grade:

Classroom:


Reason for medication:


Medication:

Medication Name

Start Date

Stop Date

Dosage

Route

Frequency

Side Effects

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Emergency Contact:

Describe

Name

Phone Number

Parent / Guardian
 
 
Health Care Provider
 
 
Pharmacy
 
 

Health Care Provider Signature:


I give permission to my child, (child’s name), to be given the above medication(s) as prescribed. And I should notify the school of any changes.  


Parent / Guardian Signature:


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