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Clark County School District Health Services Department 9998-500643 CCF-643 Rev. 12/07 PARENT/GUARDIAN REQUEST FOR MEDICATION ASSISTANCE SCHOOL YEAR Name of Student (please print): Birthdate: Teacher:
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How to fill out medication release form

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How to fill out a medication release form:

01
Start by writing your full name, date of birth, and contact information at the top of the form.
02
Provide the name and contact information of your healthcare provider or primary physician.
03
Indicate the medications you are currently taking, including the name, dosage, and frequency of each medication.
04
If applicable, mention any allergies or adverse reactions you have experienced with certain medications in the past.
05
Specify the healthcare facility or pharmacy where your prescriptions are filled.
06
If you have a designated caregiver or family member who assists with your medication management, include their name and contact information.
07
Read the terms and conditions carefully before signing and dating the form.

Who needs a medication release form:

01
Patients who are under medical treatment and need to share their medication information with other healthcare providers or facilities.
02
Individuals who require assistance with medication management, such as those living in long-term care facilities or receiving home healthcare services.
03
In some cases, employers may request a medication release form if the employee's job involves safety-sensitive tasks or the use of certain medications could affect job performance.
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A medication release form is a document that allows a healthcare provider to release information regarding a patient's medications to another party.
Healthcare providers, patients, or authorized individuals are required to file a medication release form.
To fill out a medication release form, one must provide information about the patient, the medications being released, and the purpose of the release.
The purpose of a medication release form is to allow healthcare providers to share information about a patient's medications with other healthcare providers or caregivers.
The medication release form must include details about the patient, the medications being released, and the reason for the release of information.
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