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NORTHPORT SCHOOL DISTRICT AUTHORIZATION TO CARRY/SELF ADMINISTER EPINEPHRINE () Students Name ___ DOB___ Grade/Teacher___ School___Diagnosis:___MALADMINISTRATION OF EPINEPHRINE MEDICATION () (To be
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How to fill out epi-pen self carry form
How to fill out epi-pen self carry form
01
Obtain the epi-pen self carry form from your healthcare provider or pharmacist.
02
Fill out your personal information including name, address, date of birth, and emergency contact information.
03
Provide information about your medical condition that requires the use of an epi-pen.
04
Include details about your allergies and triggers that may cause a severe allergic reaction.
05
Sign and date the form to confirm that the information provided is accurate.
Who needs epi-pen self carry form?
01
Individuals who have been prescribed an epi-pen by their healthcare provider.
02
Those who have a history of severe allergic reactions or anaphylaxis.
03
People who may be at risk of coming into contact with allergens that could trigger a reaction.
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What is epi-pen self carry form?
Epi-pen self carry form is a form that allows individuals to carry an epi-pen for emergencies related to severe allergies.
Who is required to file epi-pen self carry form?
People who require an epi-pen for severe allergies are required to file the form in order to legally carry the epi-pen.
How to fill out epi-pen self carry form?
To fill out the epi-pen self carry form, individuals must provide details about their allergies, the prescribed epi-pen medication, and emergency contact information.
What is the purpose of epi-pen self carry form?
The purpose of the epi-pen self carry form is to ensure that individuals with severe allergies have access to life-saving medication in case of an emergency.
What information must be reported on epi-pen self carry form?
The epi-pen self carry form must include details about the individual's allergies, the prescribed epi-pen medication, and emergency contact information.
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