School

Emergency treatment medication

This form must be signed and dated by the parent or guardian requesting medication administration at school. The
medication must be in the original labeled container from the pharmacy if it is prescribed or from the manufacturer if it
is a nonprescriptive medication.
Studant name: Grade:

Name of acute or chronic problem:

Prescriber's name (if applicable): Date:

Medication: Amount of medication (in the container):

Specify when the remedy must be used:

Specify how to use the remedy correctly:

There are some special care requirements during treatment? If YES, please specify.

Potencial side efects of treatment:

Dose: Route:

Observations:

The Emergency treatment medication has been reviewed and signed by:

Signature: Date:

Version 01 11/09/2020