ࡱ> 8:7c 7bjbj 8"xY\xY\& ttttt8$D$#######$&&(`#t#tt#[[[tt#[#[[:'","9!i^S" #$0D$]"R<)<)"<)t"[##MD$<)> :: SIU Family and Community Medicine Anna Jonesboro School Health Center Over-The-Counter Medication Dispensation Authorization Form Childs Name: ______________________________ Date of birth: ______________Grade: __________ Parent/Guardian: ___________________________ Best phone #: ______________________________ Below is a list of over-the-counter medications (and/or their generic equivalent) used by the SIU Family and Community Medicine Anna Jonesboro School Health Center nursing service: Tylenol: headache, menstrual cramps or musculoskeletal pain (if cant take ibuprofen) Motrin: headache (if no head trauma), menstrual cramps, musculoskeletal pain, tooth pain Midol- menstrual cramps Benadryl: allergic reaction, allergies, itching Zyrtec: allergic reaction, allergies, itching Tums/Pepto Bismol: nausea, abdominal cramping, heart burn, (we ensure no fever before giving) Immodium/Gas X- diarrhea without fever, gas or bloating Cepacol lozenges: sore throat Cough drops/ Robitussin cough syrup: cough Sudafed: congestion, common cold symptoms Eye Drops- Dry, irritated, itching eyes (not pink eye) Solarcaine/ Burn spray- minor burns, sunburns Carmex- Dry cracked lips Icy Hot- muscle pain Calaclear/ Calamine- Poison Ivy Glucose tablets: low blood sugar of known diabetic Hydrocortisone cream: applied to certain rashes that itch or bug bites Triple Antibiotic ointment: cuts, dressing wounds Contact solution: contact issues Normal saline: clean wounds Rubbing alcohol: clean piercings Orajel: tooth pain Hydrogen peroxide: clean dirty wounds By signing below (please initial EACH): _____ I request and consent to the dispensation of the previously listed medications (generics used for cost savings) for the previously listed reasons. Please check mark one: Give as needed. Do not give. _____ I hereby release and hold harmless the SIU Family and Community Medicine Anna Jonesboro School Health Center, SIU Family Medicine, SIU School of Medicine, SIU HealthCare and AJCHS from any and all liability for acting in conformance with this authorization and consent and in a manner consistent with the reasonable standards of care in the community under these circumstances. Parent/Guardian/Child has the right to refuse services. _____ I understand these services will be documented in the student school health record. _____ I understand this consent applies to the childs entire high school career. I can make changes in writing or by completing a new form. 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