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The date of next scheduled visit or when advised to return to the Prescriber 4. Consent for self administration provided the school nurse determines it is safe and appropriate Yes No Signature of Licensed Prescriber Date If not in violation of confidentiality Revised 8/2011 kc. Por favor lleve este formulario al doctor de su ni o. LYNN PUBLIC SCHOOLS SCHOOL HEALTH SERVICES Medication Delivery in Schools MEDICATION ORDER FORM Name of StudentDate of Birth Sex Address School Gr/Rm This section...
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