Physician's Medication Authorization

Yeshivas Lev Simcha Medication Authorization form:

This form is to provide medical and parental authorization for medication to be provided during Yeshiva hours. This form is the physician portion of this authorization form and must be completed entirely, signed, and returned to the school before the medication may be administered. Over the counter medication such as Tylenol, cough syrup, Benadryl, Advil, and nutritional supplements also need this form filled out completely including the physician section.

The following section is to be completed by the prescribing physician:

The student named in this document is under my medical supervision for the diagnosis described below. I have prescribed the following medication which is necessary to be given in Yeshiva. I am aware that this physician prescribed service may be administered by trained non-medical staff. NOTE: A separate form must be completed for each medication prescribed or any change.

Diagnosis for which medication will be required at school:

Name of Medication (example: Ritalin)

Dosage (number of milligrams)

Frequency: If medication is to be given at “scheduled times”, at what time(s)? If medication is to be given “when needed”, when would it be indicated and how many times can it be given?

Name of Medication (example: Ritalin)

If applicable, is student authorized to carry and use asthma inhalation medication, epinephrine auto-injection, or pancreatic enzyme supplement and self-administer:

Yes

List any significant side effects of the medication

Length of time (duration) medication is recommended

Physician's Name

Physician's Phone

Physician's Address

Physician's Signature

Select a date

Thanks for submitting!

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Physician's Medication Authorization Form