PhysAuthMedN71.5 rev. 5/2010
Physician and Parent Authorization for Medication at School
Name of student Birth date
To Be Completed By The Physician:
1. Condition for which the medication is to be given:
Strength, Dose, and Time Medication is Given:
3. Possible reactions, side effects and special instructions:
4. Purpose of Medication:
6. Medication to be continued until:
Physician’s Signature Date
Physician’s Address Phone
To Be Completed By Parent or Guardian
We will notify the school immediately if the health status of my child changes, we change physicians, or the medication is
changed or cancelled. We understand that whenever possible, the medication should be given before or after school hours.
Medication must be in the original container and properly labeled with medication name, student name, dosage, and time to be
given. All medication (prescription & Over-The-Counter) will be administered according to the Medication Policy.
I request the medication specified by the physician be given to the above named student. I will not hold liable the NBISD or
employees for any adverse reaction, allergic reaction, or side effects my child could have due to taking this medication.
authorize the physician to release medical information regarding my child to school health or administrative personnel.
Parent or Guardian Signature Date
Home Phone Work Phone Cell Phone
New Braunfels Independent School District
430 W. Mill, New Braunfels, Texas 78130
Phone: 830.643.5700 | Metro: 830.606.1423 | Fax: 830.643.5701
Email: email@example.com | http://www.nbisd.org
Please return to: