Lebanon, TN 37090

MJHS Phone: 615-758-5606

MJHS Fax: 615-758-5645

PHYSICIAN FORM FOR MEDICATION AND PROCEDURES

The Wilson County Board of Education requires the following information when students need prescription medication and/or a procedure at school. This form must be completed and signed by the physician and parent/guardian before medication can be accepted or a procedure can be performed.

1. Student’s Name__________________________________________________DOB_______________

2. Address____________________________________________________________________________

3. School________________________________________Grade______Teacher___________________

________________________________ __________ _______________ _______________

Parent/Guardian Signature Date Daytime Phone Cell Phone

_________________________________________ _____________ ___________________ ___________________

Emergency Contact Relationship Daytime Phone Cell Phone

TO BE COMPLETED BY PHYSICIAN ONLY

4. Medication_______________________________________Dosage/Time________________________

5. Student Competent to Self-Administer Medication with Assistance? Yes_____ No_____

6. Home Dosage and Time_______________________________________________________________

7. Dates to Administer Medication at School From___________________to____________________

8. Side Effects_________________________________________________________________________

9. Allergies____________________________________________________________________________

PROCEDURE

10. Procedure__________________________________________________________________________

11. Student Competent to Perform Procedure Yes_____ No_____

12. Time/Times Performed at School______________________________________________________

_______________________________________ __________ _______________ _______________

Physician’s Signature Date Office Number Fax Number

Please note that if medication or procedure changes are made

new documentation must be provided by the physician