SAMPLE
District Letterhead
Agreement for Physician/Clinic
Consultant Services
(It is recommended that any agreement between the LEA and Health Care Provider be
renegotiated annually.)
The following services will be provided by <Clinic/Hospital/County Health
Department> to <School District/County Office of Education>.

Review protocols for emergency treatment of anaphylaxis.

Review and sign standing orders for epinephrine auto-injectors.

Provide written script/prescription for ( #) epinephrine auto-injectors.

Provide phone consultation related to training and supervision of volunteer
designated school employees for the emergency care of individuals suffering from
anaphylaxis.
These services are provided through a mutual agreement between
<Clinic/Hospital/County Health Department> and <School District/County Office of
Education>.
Clinic/Hospital/County Health Department
(Date)
District/County Office of Education
(Date)