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Medical Authorization Form
Student Name: _______________________________________ Grade: ______ Name / Type of Medication: __________________________________________________________ Dosage / Amount to be given: __________________________________________________________ Frequency / Times to be Administered:______________________________________________ Duration (week/month/indefinite/etc.) _________________________________________________________ Effective Date: from ________________________ to ________________________ Physician's Name: _____________________________________ Phone: _________________________ Parent Signature: _____________________________________ Date: _______________ Parents' Daytime phones: ____________________ ______________________ |