Microsoft word - parent form med consent_albuterol [rev 1].doc

Plymouth Public Schools
Parent/Guardian Consent for Medication Administration
(Page 1 of 2)
Student: _______________________________________

Date of Birth: ______________ Grade: ____________ Date of Consent: __________
My son/daughter is known to have the following allergies:________________________
Diagnosis (if not in violation of confidentiality):
1. I request and give permission to the school nurse to give my son/daughter: Medication: Albuterol
Prescribed by: ___________________________________________________ 2. I give permission for my son/daughter to self-administer (carry the medication and administer by him/her-self during class/field trip) NOT in the presence of the school
nurse. Note: Self administration is reserved for students who have an Epi-pen,
enzyme supplement, inhaler or diabetic supplies as per the regulations of the
Commonwealth of MA.
Not Applicable
If I give my permission, I understand the school nurse and I must be in agreement that my student demonstrates the ability and understands all aspects of administration of this medication as directed. I also agree to provide a back-up supply for the nurse to keep in the health office in the event my student does not have his/her prescribed medication/supplies in his/her possession when needed. 3. I give permission to the school nurse to share with appropriate school personnel information relative to the prescribed medicine administration as s/he determines necessary for my child’s health and safety. 4. I understand that in the event of a field trip, this medication administration plan may need to be adjusted and I will do the following: Call the school nurse prior to the field trip to discuss the plan for This medication may be withheld (not given) on the day of the field trip. Not Applicable - Self administration selected in #2 above 5. I understand that I may retrieve the medicine from the school at any time, and that the medicine will be destroyed if it is not picked up within one week following the termination of the order or the last day of school.
Parent/Guardian Signature: ___________________________ Date: _____________
Plymouth Public Schools
Parent/Guardian Consent for Medication Administration
(Page 2 of 2)
MEDICATION ADMINISTRATION PLAN (To be completed by the School Nurse)
Medication: ALBUTEROL (ProAir, ProVentil, Ventolin)
Duration of Medication:
Date Ordered:
Expiration Date of Medication:
Time to be Given: PRN Bronchospasms
Quantity Received:
Contraindications/Side Effects:
Use cautiously in patients w/ Diabetes. Risk of paradoxical bronchospasm. May increase CNS stimulation, decrease digoxin levels, and cause mutual antagonism of propranolol and other beta blockers. Can cause: tremors, nervousness HA, hyperactivity, dizziness, weakness, tachycardia, palpitations, hypertension, dry & irritated nasal mucosa, nasal congestion, epistaxis, hoarseness, muscle cramps, cough, wheezing, dyspnea, bronchitis, bronchospasm. Onset/Peak/Duration: O: 5-15 minutes
P: 30-120 minutes
IHCP Indicated:
Original MD order received:
Entered into Health Office Computerized Database :
Medication Administration Record completed and placed in medication book:
School Nurse Signature:
Date: ______________
Parent form med consent_Albuterol [Rev 1].doc February 23, 2010 Revised 08/2010


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