Doctor's Order
To be completed by a Licensed Prescriber: Physician, Nurse Practitioner or others authorized by Chapter 94C.
Student’s Name: __________________________________Date of Birth:___________
Address: ________________________________________Grade: ________________
Licensed Prescribers Name: ___________________________________Title: _______
Business Telephone Number: ______________________________________________
Medication: _____________________________________Dosage_________________
Route of Administration: __________________________Frequency: ______________
Specific Time of Administration: ____________________________________________
Specific directions or information for administration: ____________________________
________________________________________________________________________
Date of Order: ________________________Discontinuation Date: ________________
Diagnosis: ______________________________________________________________
Any other medical condition(s)* _____________________________________________
Optional Information:
1. Specific side effects, contraindications, or possible adverse reactions to be observed.
2. Other medication being taken by the student: ________________________
3. The date of the next scheduled visit or when advised to return to prescriber
__________________________.
4. Consent for self administration (provided the school nurse determines it safe and appropriate) Yes _______ No ______
Signature of Licensed Prescriber Date
*if not in violation of confidentiality.
| 
