CA Covina-Valley Unified School District Epi-Pen/Adrenaclick Administration Health Care Plan 2019-2025 free printable template

COVINAVALLEY UNIFIED SCHOOL DISTRICT STUDENT SERVICES EpiPen / Adrenaline Administration Health Care Plan TO BE COMPLETED BY PARENT/GUARDIAN:Student Name___ DOB___ School___ I request that designated

How to fill out CA Covina-Valley Unified School District Epi-PenAdrenaclick

How to fill out epi pen authorization form

1. Obtain the epi pen authorization form from a healthcare provider or school nurse.
2. Fill out the patient's personal information such as name, age, and contact details.
3. Provide details of the medical condition that requires the use of an epi pen.
4. Indicate any known allergies or triggers that may cause an allergic reaction.
5. Specify the dosage and frequency of epi pen administration as prescribed by a healthcare provider.
6. Sign and date the form to indicate consent and acknowledgement of the information provided.

Who needs epi pen authorization form?

1. Individuals who have been prescribed an epi pen by a healthcare provider.
2. Students who require an epi pen to be kept at school for emergency use.
3. Employees who may come into contact with allergens in the workplace.

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What is epi pen authorization form?

The epi pen authorization form is a document that authorizes the administration of an epinephrine auto-injector (epi pen) in case of an allergic reaction.

Who is required to file epi pen authorization form?

Parents/guardians of children with severe allergies, schools, and other establishments where individuals with allergies may be present are required to file epi pen authorization forms.

How to fill out epi pen authorization form?

The epi pen authorization form typically requires information such as the individual's name, age, allergies, emergency contact information, physician's information, and the specific instructions for administering the epi pen.

What is the purpose of epi pen authorization form?

The purpose of the epi pen authorization form is to ensure that individuals with severe allergies have access to potentially life-saving medication in case of an allergic reaction.

What information must be reported on epi pen authorization form?

Information such as the individual's name, age, allergies, emergency contact information, physician's information, and specific instructions for administering the epi pen must be reported on the epi pen authorization form.