Minford Middle School Minford Local School District Administration of Medication Physician's Statement (As Required by Ohio Law)

Student's Name ______________________________________________  Date ___________________

Student's Address ____________________________________________ City ____________________

School _____________________________________________________ Grade ___________________

Name of Prescription __________________________________________

Date Drug is to begin __________________________________________ And end _________________
 

Any severe reactions that should be reported to the physician: ___________________________________

___________________________________________________________________________________

Special instructions: ___________________________________________________________________

___________________________________________________________________________________
 

________________________________________     ________________________________________
                Physician's Signature                                                     Physician's Phone Number & Date
 

Important Information:
The parent or guardian agrees to submit a revised statement signed by the physician if any of the information
originally provided by the physician changes.

The drug must be received by school authority in the container in which it was dispensed by the prescribing
physician or licensed pharmicist.

Parent or Guardian Request

I hereby give my permission for ________________________________________to be administered the
above prescription drug as prescribed by his/her physician.

____________________________________      _____________________________________
            Parent or Guardian Signature                                                        Address