Clinical Forms

Clinical Forms

Clinical Forms

Please pay close attention to these forms. Some will need to be filled out by both parent AND the physician.

Medication to be given at school MUST: be brought in its original container by an adult, have the original pharmacy label on the container, and have a prescription medication administration form signed by both the doctor and the parent/guardian.

Any medication change will require: a new doctor’s order, a new original pharmacy container and label, a new prescription medication administration form signed by both the doctor and the parent/guardian.

  • All medication is kept in a locked cabinet in the clinic.
  • Medications received by the school are tracked and logged on the student’s medication administration form.
  • Medications are counted when parents bring in new medicine.
  • Medication is tracked to make sure that the medication is not lost, stolen, or administered incorrectly.


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Printable Forms

This form is for children who will need to take medication at school that has been prescribed by their physician. The form must be filled out and signed by the physician.
This form is for children who will need medication at school that has been prescribed by their physician. The form must be filled out and signed by the parent/guardian.
This form is for children who have an inhaler prescribed for them to help with asthma symptoms. This form authorizes the school to possess and use an inhaler. This form must be signed by both the parent/guardian and the physician.
This is a form that needs to be filled out by parent/guardian of students who have asthma that may require use of an inhaler. This form does not serve as permission to give the inhaler, but rather as information for school staff to have on hand regarding your child’s condition and possible reaction. This form is to be filled out and signed by the parent/guardian.
This is a form that needs to be filled out by parent/guardian of students who have a severe allergy that may require use of an Epi-Pen. This form does not serve as permission to give the Epi-Pen, but rather as information for school staff to have on hand regarding your child’s allergy and possible reaction. This form is to be filled out and signed by the parent/guardian.
This is a form that needs to be filled out by parent/guardian of students who have a seizure condition. This form serves as information for school staff to have on hand regarding your child’s seizure condition. This form is to be filled out and signed by the parent/guardian.
This provides information regarding the MVHC school linked health center. These forms need to be filled out and signed by parent/guardian if you want your child to be able to receive medical and dental services from Muskingum Valley Health Center while at school. They do NOT have to be a regular patient at MVHC to use these services.
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