Heartwood School
Medication and Treatment Administration Form
Attention PARENT/GUARDIAN/ or GROUP HOME MGR: Please complete the TOP SECTION
(ONLY) and return the form to the Heartwood School Clinic.
STUDENT NAME:_______________________________________________ BIRTHDATE:__________________
Medication
Dose/Amount
Time(s) given @ school
Time(s) given @ home
Please check any over-the-counter (OTC) medications (below) that your student may receive at
school. We request permission to administer these OTC meds. when the student needs them.
This prevents delays in symptom relief.
Tylenol/Acetaminophen tablet/elixir, per student weight, every 4-6 hours. as needed (PRN) for fever or discomfort
Ibuprofen/Motrin tablet/elixir, per student weight, every 4-6 hours. as needed (PRN) for fever or discomfort
Benadryl/Diphenhydramine, 12.5mg–25mg per student weight., 4-6 hrs. PRN for allergy-type symptoms
Doctor’s Name & Phone: ___________________________________________________________
I hereby authorize Heartwood School to administer the medication(s) and or treatment(s)as prescribed.
Parent/Guardian/Resident Mgr. Signature: ____________________________________ Date:________________
Parent/guardian – STOP HERE, please. The School Nurse will forward it to the doctor to sign.
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DOCTOR or NURSE to review or edit medications/treatments and return to Heartwood School Clinic.
DOCTOR/NURSE to sign below and return by FAX to: 517 676-5302
or mail to:
Heartwood School Nurse
625 Hagadorn Road
Mason MI 48854
Attn: R.N. at Heartwood School Clinic
Phone (517) 244-1420
DOCTOR’S ORDERS:
Type(s) of medication or treatment and the dosage is to be given in the amount of tablets/capsules/teaspoons/
cc’s/ml’s daily or as follows:
Possible Side Effects: _________________________________________________________________________
Duration:
Current School Year
Other:_____________________________________________________
The Registered Nurse at Heartwood School has permission to give medication or treatment as directed above.
Doctor’s Signature:
Date: ______________________
Forms/Medication & Treatment Form NEW