Banner Christian School Rev 6.15.23

5831 Courthouse Rd Chesterfield, Virginia 23832 Phone: 804-276-5200 Fax: 804-946-4059

www.bannerchristian.org

11 or MORE DAYS - WRITTEN MEDICATION CONSENT FORM

Please complete in a language in which the MAT personnel can understand. No medical abbreviations or shorthand.

One form MUST be completed for each MEDICATION. Multiple medications cannot be listed on one consent form.

PHYSICIAN or HEALTH CARE PROVIDER (section # 1 to # 18)

1. Child’s first and last name:

2. Date of Birth

3. Child’s known allergies:

4. Name of medication (including strength):

5. Amount/dosage to be given:

6. Route: ___ oral ___ inhaled ___ topical ___patch ___ eye ___ ear ___ nebulizer ___ injected

7a. Frequency to be administered: ______________________________________________________________________

OR

7b. Identify the signs and/or symptoms that will necessitate administration of medication

__________________________________________________________________________________________________________________

8a. Possible side effects: _____ See package insert or pharmacy printout for complete list of possible side effects. 8b. Additional side effects: __________________________________________________________________________________________

9. What action should the MAT personnel take if side effects are noted?

____ Contact parent (phone #_______________________) ____ Contact Health Care Provider (phone # ________________________)

____ Contact 911 _____ Other:__________________________________________________________________________________

10a. Special instructions: ____Parents will supply package insert or pharmacy printout for complete list of special instructions AND/OR 10b. Additional special instructions: _________________________________________________________________________________________

11. Reason the child is taking this medication (unless confidential by law):_________________________________________________

12. Does the above named child have a chronic physical, developmental, behavioral or emotional condition expected to last 12 months or more, and requires health and related services of a type or amount beyond that required by children generally: ____ no ____ yes If you checked YES, you need to complete #33 and #34 on the back of this form.

13. Are the instructions on this consent form a change in a previous medication order as it relates to the dose, time, or frequency the medication is to be administered? ____No ____Yes - If you checked YES, you need to complete #35 and #36 on the back of this form.

14. Date consent form completed:

15. Date to be discontinued if prior to 10 days:

16. Prescriber’s Name: (please print)

17. Prescriber’s Phone Number:

18. Licensed authorized health care provider’s signature:

OVER

11 or MORE DAYS - WRITTEN MEDICATION CONSENT FORM

PARENT/GUARDIAN MUST COMPLETE THIS SECTION (#19 TO #23)

19. If Section #7a is completed, do the instructions indicate a specific time to administer the medication? (example: 10:00 am) __ No __ Yes __ N/A If yes, write the specific time(s) the MAT personnel is to administer the medication:________________________

20. I, parent/legal guardian, authorize the Banner MAT personnel to administer the medication as specified to my child:

______________________________________ Child’s full name

21. Parent/legal guardian name: (please print)

22. Parent/legal guardian signature:

23.Date Authorized:

BANNER CHRISTIAN TO COMPLETE THIS SECTION (#24 TO #30)

24. Provider/School Name:

BANNER CHRISTIAN SCHOOL

25. Facility Phone Number: 804-276-5200

26. (leave blank)

27. I have verified that #1 to #23 and if applicable, #33 to #36 are complete. My signature indicates that all information needed to give this medication has been given to Banner Christian School.

28. MAT Personnel: (please print)

29. MAT Personnel Signature:

30. Date received from parent/legal guardian:

#31 AND #32 SHOULD ONLY BE COMPLETED IF THE PARENT REQUEST TO DISCONTINUE THE MEDICATION

PRIOR TO THE DATE INDICATED IN SECTION #15

31. I, parent/legal guardian request that the medication indicated in section #4 on this consent form, be discontinued on (date)___________. Once the medication has been discontinued, I understand that if my child requires this medication in the future, a new Written Medication Consent Form MUST be completed in its entirety.

32. Parent/Legal Guardian signature: ______________________________________________________

LICENSED HEALTH CARE PRESCRIBER TO COMPLETE, AS NEEDED (#33 TO #36)

33. Describe any additional training, procedures, or competencies that Banner’s MAT personnel will need to care for this child:

_____________________________________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

34. Licensed Health Care Prescriber’s Signature: ______________________________________________ Date: ____________________

35. Since there may be instances where the pharmacy will not fill a new prescription for changes in a prescription related to dose, time or frequency until the medication from the previous prescription is completely used, please indicate the date by which you expect the pharmacy to fill the updated order. Date: _________________________

By completing this section, Banner Christian School, will follow the written instructions on this form and NOT follow the pharmacy label until the new prescription has been filled.

36. Licensed Health Care Prescriber’s Signature: _______________________________________________ Date:____________________