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DIOCESE OF CHARLOTTE SELF-MEDICATING STUDENT / PARENT / PHYSICIAN AGREEMENT FOR, EPI PENS AND ASTHMA MEDICATION ONLY PHYSICIAN AGREEMENT: I have provided education to (Students Name) and given the
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How to fill out self-medicating student parent physician?

01
Start by obtaining the necessary form. You can usually find the self-medicating student parent physician form from your child's school or educational institution. Contact the school administration or health services department to request the form if it is not readily available.
02
Carefully read and understand the instructions. The form may have specific guidelines and requirements that need to be followed. Make sure to familiarize yourself with any deadlines or additional documents that may be necessary to complete the process.
03
Fill in your personal information. Provide your full name, contact information, and any other details that are required. Double-check for accuracy and make sure that all the necessary fields are properly filled out.
04
Provide information about your child. Include your child's name, date of birth, and any relevant medical conditions or allergies. This will help the physician understand your child's specific needs and make appropriate recommendations.
05
Indicate the medications your child requires. List all the medications that your child needs to take during school hours. Include the medication name, dosage, frequency, and any special instructions or precautions. It's important to be as detailed and comprehensive as possible to ensure your child's safety and well-being.
06
Include any necessary signatures. The form may require both your signature as the parent or guardian, and the physician's signature. Make sure to sign and date the form, and if needed, have the physician sign and provide their contact information as well.
07
Review and submit the completed form. Before submitting the form, take a moment to review all the information and ensure its accuracy. If you have any doubts or questions, reach out to the school or physician for clarification. Once you are confident that everything is filled out correctly, submit the form according to the provided instructions.

Who needs self-medicating student parent physician?

01
Students with chronic health conditions. Students who have chronic health conditions like asthma, diabetes, epilepsy, or severe allergies may require self-medication during school hours. The self-medicating student parent physician form allows the school to be aware of the student's medical needs and ensures that the necessary medications can be administered safely.
02
Parents or guardians of students. The self-medicating student parent physician form is typically filled out by the parents or legal guardians of the students. It is their responsibility to provide accurate information about their child's medical needs and ensure that the proper medications are available for self-administration.
03
Physicians or healthcare providers. The physician or healthcare provider plays a crucial role in this process. They are responsible for assessing the student's medical needs, prescribing the necessary medications, and providing the required information and signatures on the form. Their involvement is essential to ensure the student's health and well-being are properly addressed during school hours.
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