Physician's Authorization for Prescription Inhaler

STUDENT'S NAME: _________________________________  DOB: _______________

NAME OF INHALER: _____________________________________________________

# OF INHALATIONS AND TIME INTERVAL: ____________________________________

PLEASE CHECK ALL THAT APPLY:

_____    STUDENT MUST CARRY INHALER AT ALL TIMES.

_____    STUDENT DOES NOT NEED TO CARRY INHALER, IT SHOULD BE AVAILABLE
                    IN THE HEALTH ROOM.

_____    INHALER SHOULD BE USED _____ MINUTES PRIOR TO EXERCISE.

OTHER TREATMENT TO BE USED IN CASE OF SEVERE ATTACK:  ________________

_______________________________________________________________________

POSSIBLE ADVERSE REACTIONS AND INTERVENTIONS:

_______________________________________________________________________

_______________________________________________________________________

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PHYSICIAN'S SIGNATURE: __________________________  DATE: ________________

ADDRESS: _________________________________  PHONE: ____________________

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I hereby give the Nurse at Hillcrest Middle School my permission to contact the above named
Physician's office to request medical information concerning my child.

Parent's Signature: __________________________________  Date: ________________