Fax form

School medication to administer request
For your convenience, use this form to fax your request that a child be administered medicine in school.

Instructions
Print this form. Please be sure to fill out all the blanks to ensure proper processing of your request. Fax it to your primary office below.

• Download this pdf form and print it using Adobe Acrobat Reader.

Primary office fax numbers:

Camillus office FAX: (315) 487 - 3485

Liverpool office FAX: (315) 652 - 4679

Please fill out completely

Patient / parent information

Patient's name: __________________________________________________

Patient's birthday: _____________________________________________

Patient's primary care physician: ____________________________________

Parent's name: ________________________________________________

Address: _________________________________________

Phone number: ____________________________________

Prescription information

Name of drug: ____________________________________

Dosage: ________________________________________

Time medication is to be taken at school: ________________

Condition for which medication is to be given: ___________________________