Authorization to Administer Tylenol

AUTHORIZATION TO ADMINISTER TYLENOL
GRADES 5 - 8

 

      (   )  I AUTHORIZE the School Nurse to administer Tylenol as per standing orders* to my child during                   school hours

(   ) I DO NOT AUTHORIZE the School Nurse to administer Tylenol to my child during school hours


STANDING ORDERS:
Headache:  limit administration to two occurrences/month or three consecutive days
Dysmenorrhea: limit administration to 5 days/month
Dental Pain:  limit administration to 4 day following dental/orthodontia work
Temperature:  greater than 101 degrees



Parent Signature_____________________________   Child’s Name/Date__________________________