Medication Agreement for Allergy TreatmentMedication Agreement • January 15th, 2007
Contract Type FiledJanuary 15th, 2007Medication Dose Route Frequency Medication used for Side Effects Medication Dose Route Frequency Medication used for Side Effects Printed Name of Prescribing Practitioner: □ This order is effective for the period from to Month / Day / Year Month / Day / Year □ The student has been instructed by me or a member of my staff when & how to use his/her EpiPen. □ This student is capable of self administration of anaphylaxis treatment. □ This student is not able to carry his/her allergy medication. Prescribing Practitioner Signature Date