Lakeside Union School District
Health Services
Physician’s Authorization for Treatment of All Allergies
Student: __________________________________________________ DOB: ________________
Teacher: __________________________________________________ School: ______________
A. To Be Completed By Parent/Guardian
I hereby request that Lakeside Union School District, through its designated authority, supervise and or assist in
the administering of medication to my child,
according to the instructions
contained on my physician’s statement below. I release the Board of Trustees, the school, and any employee from
liability for administering any authorized medication.
___________________________________________________
Parent or Legal Guardian’s signature
____________________________________
____________________
Phone#
Date
B. To Be Completed By Physician Only
Allergy to:
Life-Threatening? Yes
Symptoms:









No
Treatment: Give checked Medication
If a food allergen has been ingested, but no symptoms:
Mouth Itching, tingling, or swelling of lips, tongue, mouth:
Skin hives, itchy rash, swelling of face or extremities:
Stomach- nausea, abdominal cramps, vomiting, diarrhea:
Throat- tightening, hoarseness, hacking cough:
Lung- Shortness of breath, repetitive coughing, wheezing:
Heart- Weak or thready pulse, low blood pressure, fainting:
Other:
If reaction is progressing (several above areas affected) give:
Epinephrine
Epinephrine
Epinephrine
Epinephrine
Epinephrine
Epinephrine
Epinephrine
Epinephrine
Epinephrine
Antihistamine
Antihistamine
Antihistamine
Antihistamine
Antihistamine
Antihistamine
Antihistamine
Antihistamine
Antihistamine
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Dosage:

Epinephrine: inject intramuscularly according to above guidelines. (circle one)
EpiPen 0.3mg


EpiPen Jr. 0.15mg
Twinject 0.3mg
Twinject 0.15mg
Antihistamine: give according to above guidelines.
(medication, dose, route)
.
Other:
(medication, dose, route)
.
Monitoring:
Stay with student; alert EMS, parent, and District Nurse. Tell EMS epinephrine was given. Note time epinephrine was
administered. A second dose of epinephrine can be given 5 min. or more after first dose if symptoms persist or recur. For a
severe reaction, consider keeping student lying on back with legs raised. Treat student even if parents cannot be reached.
**This form will need to be updated at the beginning of each school year**
________________________
___________________
______________
Printed name of physician
Medical license number
Telephone number
____________________________________
____________________________
Physician Signature
Date