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Oklahoma City Public Schools Health Services Permission Form for Over the Counter Medications
School: ______________________ Phone #: ____________________ Fax #: _______________________ Date form received by the school: Student: _______________________Date of Birth or Age: _________ Grade: ________________Teacher/Classroom:___________________________ To be completed by the Parent or Guardian: Reason for Medication: ______________________________________________ Name of Medication: ________________________________________________ Form of Medication/Treatment: _______________________________________ ___Tablet ___Liquid ___Other Instructions (Schedule and dose to be given at school): ___________ ________________________________________________________ Start: ___Date form received Other date: ________ Stop: ___End of school year Other date: ________ ___For episodic/emergency events only
Restrictions and/or important side effects: ___None anticipated ___Yes If yes, please describe: _______________________________________ Special storage requirements: ___None ___Refrigerate ___Other To be completed by the parent/guardian: I give permission for (name of child) ___________________________________ to receive the above medication at school according to standard school policy. THE MEDICATION MUST BE BROUGHT TO SCHOOL IN THE ORIGINAL UNOPENED CONTAINER.
Date: _________ Signature: _____________________Relationship___________ Phone: ____________Other phone numbers: ___________________________ DJ 10-22-03
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