CONSENT FORM FOR PHYSICIAN-PRESCRIBED SERVICES

PHYSICIAN’S ORDER FOR PHYSICIAN-PRESCRIBED SERVICES (PPS)

1. NAME OF PUPIL_________________________________ BIRTH DATE____________

2. ADDRESS____________________ CITY _____________________ ZIP ______________

3. CONDITION TO BE TREATED _____________________________________________

4. PHYSICIAN-PRESCRIBED SERVICE (PPS) __________________________________

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5. CHECK ONE:

____ I HAVE REVIEWED AND APPROVED THE STANDARDIZED PROCEDURES AS WRITTEN ON the PARENT RELEASE.

____ I HAVE REVIEWED AND APPROVED THE STANDARDIZED PROCEDURES ON the PARENT RELEASE., WITH MY MODIFICATIONS.

____ I HAVE ATTACHED MY RECOMMENDATIONS FOR STANDARDIZED PROCEDURES.

6. PRECAUTIONS, POSSIBLE SIDE EFFECTS, AND RECOMMENDED INTERVENTIONS:

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7. TIME SCHEDULE AND/OR INDICATIONS FOR PPS (PPS MAY ONLY BE SCHEDULED DURING SCHOOL HOURS. PPS WHICH CAN BE ADMINISTERED BEFORE OR AFTER SCHOOL INSTEAD OF DURING THE SCHOOL DAY WILL NOT BE ADMINISTERED BY SCHOOL STAFF.):

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8. I AM AWARE THAT THIS PPS MAY BE ADMINISTERED BY NON-MEDICALLY TRAINED STAFF.

9. I WILL NOTIFY THE SCHOOL IMMEDIATELY IF THIS PPS IS CHANGED AND WILL FORWARD A WRITTEN CONFIRMATION THEREOF. I WILL EXECUTE A NEW PPS FOR ANY CHANGE IN PPS.

10. THIS IS A LIST OF ALL MEDICATIONS TAKEN BY THIS CHILD:

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PHYSICIAN’S NAME _________________________________ TELEPHONE _______________

ADDRESS ___________________________ CITY _________________ ZIP________________

PHYSICIAN’S SIGNATURE ___________________________________DATE________________