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EpiPen/GLUCAGON DELEGATE PERMISSIONFORMTo the Parent/Guardian of___:
Your child has been identified as needing EpiPen/glucagon for life-threatening
anaphylaxis/insulin reaction. We have on file the
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How to fill out epi-pen delegate permission form
How to fill out epi-pen delegate permission form
01
Obtain the Epi-pen delegate permission form from the school, workplace, or organization requesting it.
02
Fill out the top section of the form with your personal information including your name, address, phone number, and relationship to the person needing the Epi-pen.
03
Provide any necessary medical information for the person needing the Epi-pen, such as their allergies or medical conditions.
04
Sign and date the form to indicate your authorization for the designated person to administer the Epi-pen when necessary.
Who needs epi-pen delegate permission form?
01
Individuals who require the assistance of others to administer an Epi-pen in case of an allergic reaction.
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What is epi-pen delegate permission form?
The epi-pen delegate permission form is a document that allows someone other than the person prescribed an epi-pen to administer the medication in case of an allergic reaction.
Who is required to file epi-pen delegate permission form?
Anyone who may need assistance in administering an epi-pen due to a severe allergic reaction is required to file the epi-pen delegate permission form.
How to fill out epi-pen delegate permission form?
To fill out the epi-pen delegate permission form, you must provide information about the person prescribed the epi-pen, the delegate who will administer the medication, and both parties must sign the form.
What is the purpose of epi-pen delegate permission form?
The purpose of the epi-pen delegate permission form is to ensure that there is a designated individual who can assist in administering the epi-pen in case of an emergency allergic reaction.
What information must be reported on epi-pen delegate permission form?
The epi-pen delegate permission form must include details about the person prescribed the epi-pen, the delegate who will administer the medication, emergency contact information, and any specific instructions for administering the epi-pen.
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