Get the free Epinephrine Auto-Injector Self-Administration Form - Davis.K12.ut.us
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SELF-ADMINISTRATION EPINEPHRINE AUTO INJECTOR (EAI) AUTHORIZATION FORM Today’s Date Student Name Birth Date Address City Emergency Contact Information: Name Phone Number Health Care Provider Authorization
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How to fill out epinephrine auto-injector self-administration form
How to fill out an epinephrine auto-injector self-administration form:
01
Begin by carefully reading the instructions provided on the form. Make sure you understand each section and its purpose.
02
Fill out your personal information accurately and clearly. This usually includes your full name, date of birth, address, and contact information.
03
Specify any relevant medical conditions or allergies that you have. Provide details about any known triggers or substances that could induce an allergic reaction.
04
Indicate if you have previously been prescribed an epinephrine auto-injector or if this is your first time using one. Include details about the brand and dosage prescribed, if applicable.
05
If you have any known allergies or medical conditions that could potentially interact with the use of an epinephrine auto-injector, mention them on the form. This information will help healthcare professionals provide appropriate care in case of an emergency.
06
Sign and date the form to certify that the information provided is accurate to the best of your knowledge.
Who needs an epinephrine auto-injector self-administration form:
01
Individuals who have been prescribed an epinephrine auto-injector by their healthcare provider may need to fill out this form.
02
This form is particularly relevant for those who have known allergies or medical conditions, such as severe allergic reactions (anaphylaxis), which might require the use of an epinephrine auto-injector.
03
Other individuals who are frequently exposed to potential allergens or have a high risk of experiencing an allergic reaction might also require an epinephrine auto-injector and, subsequently, need to complete the self-administration form.
04
It is important to consult with a healthcare professional to determine if you need an epinephrine auto-injector and whether filling out the self-administration form is necessary in your specific situation.
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