Authorization To Self-Medicate With An Inhalator

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					                        Self – Medication for Asthma Inhalers
                                  Authorization Form


Student’s Name__________________________________ Date:____________

Address:__________________________________________________________

Medication name:___________________________________________________

Dosage:__________________________________________________________

Date administration is to begin:__________________________________________

Date administration is to stop:___________________________________________

Adverse reactions that should be reported to a physician:_________________________



Procedure to follow if medication does not produce the expected relief from asthma attack:




Special Instructions:_________________________________________________

________________________________________________________________



Physician’s Name________________________ Phone:________________

Physician’s Signature_________________________ Date:_____________

Parent/Guardian Name_________________________________________

Parent/Guardian Signature______________________________________

Date:__________            Parent/Guardian Work Phone:__________________

                           Parent/Guardian Home Phone:__________________

                          Parent/Guardian Cell Phone:____________________

				
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posted:9/12/2012
language:English
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