Connecticut State Law and Regulations 10-212(a) require a written medication order of an authorized prescriber and parent/guardian written authorization for the nurse, or in the absence of the nurse, a designated principal or teacher to administer medication. Medications must be in the original properly labeled container and dispensed by a physician/pharmacist.    Parents/Guardians: please have the prescribing physician complete and sign this form, then sign and date where indicated. Use additional forms if necessary. Name of

Student:_____________________________

Date of Birth (m/d/year):______________

Allergies:_______________________________

School Attending:   ____________________

Prescriber’s  Signature: _________________________________

Date: _____________________

Prescriber’s Name/Title (type, print or stamp): ___________________________________________________________________________

Prescriber’s address: ___________________________________________________

Prescriber’s telephone: _________________________________________________

Fax:______________________________________________________________________

PARENT/GUARDIAN AUTHORIZATION: I hereby authorize that the above ordered medication be administered by school personnel and I give permission for the exchange of information between the prescriber and the school nurse necessary to ensure the safe administration of this medication. I understand that this medication will be destroyed if not picked up within one week following termination of the order or the last day of school, whichever comes first.

Parent/Guardian Signature: _________________________________

Date:______________

Parent/Guardian – Prescription Insurance Information   REMEMBER:  It is critical to forward us a copy of both sides of the insurance card of the parent/guardian and the patient.  We are always available to answer any questions you may have at (860) 927-3725.   Kent Station Pharmacy