Chesterfield School District

535 Old Chesterfield Road, PO Box 205 Chesterfield, New Hampshire

Telephone: 603-363-8301 Fax: 603-363-8406
Sharyn DEon, Principal sdeon@sau29.org

03443

Prescription Medication Order and Permission

(To be returned to the School Nurse)

Name of
Student__________________________________D.O.B.___________Teacher/Grade____________
Medication/Dosage_________________________________________________________________
Dosing
Instructions_______________________________________________________________________
Reason for
medication________________________________________________________________________
Date _______________ Signature of Physician__________________________________________

I hereby give my permission for ______________________________to receive this medication at

school as ordered. I also give permission for the physicians office and school nurse to share
this information.
Signature of Parent of Guardian_____________________________________________________________
Medication will not be given at school until the school nurse receives this completed form (Doctors
Order) with the prescribed medication in a container appropriately labeled by the pharmacy.
Date received_________________ Date to Start ____________________________
Signature of School Nurse __________________________________________________________