Medication Administration Authorization Form

Student / Patient Information

Name

Date of Birth

Grade/Class

Parent/Guardian Name

Phone Number

School/Facility Name

Medication Name

Dosage

Route

Time(s) to Administer

Start Date

End Date

Reason for Medication Special Instructions (e.g., storage, side effects, allergies)

Prescriber Name

Phone

Fax

Parent/Guardian Signature

Date

Prescriber Signature

Date