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Orange Unified School District PARENT AND PHYSICIAN REQUEST FOR MEDICATION Name of Pupil Address Birthdate Telephone # PARENT REQUEST FOR ADMINISTRATION OF MEDICATION (PRESCRIPTION AND NON-PRESCRIPTION)

How to fill out parent and physician request

How to fill out parent and physician request:

Fill in the personal information section:

1. Enter the child's full name, date of birth, and address.
2. Include the parent or guardian's name(s), contact information, and relationship to the child.
3. Provide the primary physician's name, contact information, and office address.

Provide medical history and current condition details:

1. Specify any existing medical conditions, allergies, or chronic illnesses that the child may have.
2. Mention any medications the child is currently taking or if they require any specific medical treatments.
3. Describe the reason for the request and the child's symptoms or health concerns that require attention.

State the request or authorization clearly:

1. Clearly express the purpose of the request, whether it is for a medical evaluation, treatment, medication, or referral to a specialist.
2. Specify any preferred healthcare providers or hospitals, if applicable.
3. Include any additional information or instructions that may be relevant for the physician to consider.

Obtain necessary signatures and dates:

1. Sign and date the parent/guardian section to indicate consent and authorization for sharing the child's medical information.
2. The physician should also sign and date the form to confirm their agreement to provide the requested medical attention or referral.

Who needs parent and physician request?

1. The parent or guardian of a minor child who requires medical attention, evaluation, treatment, or medication may need to fill out a parent and physician request.
2. Additionally, this type of request may be necessary when a referral to a specialist or a particular healthcare provider is needed for the child's healthcare needs.

For pdfFiller’s FAQs

What is parent and physician request?

Parent and physician request is a formal document submitted by a parent or guardian requesting accommodations or services for a child with a disability, supported by a physician's recommendation.

Who is required to file parent and physician request?

Parent or guardian of a child with a disability is required to file the parent and physician request.

How to fill out parent and physician request?

Parent and physician request must be filled out with detailed information about the child's disability, requested accommodations, and supported by a physician's recommendation.

What is the purpose of parent and physician request?

The purpose of the parent and physician request is to ensure that a child with a disability receives the necessary accommodations and services to succeed in an educational setting.

What information must be reported on parent and physician request?

Parent and physician request must include information about the child's disability, recommended accommodations, physician's recommendation, and contact information.

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