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AUTHORIZATION FOR ADMINISTERING MEDICAL TREATMENT TO CHILDREN WITH SEVERE ALLERGIES
Dear Doctor ____________________________ Date ___________________
Your patient, ________________________________ is enrolled/enrolling in our School and we have been requested to provide certain medical treatment for the prevention of anaphylaxis in the event the child comes into contact with certain allergen(s), as described below. Please complete Part I of this instruction record. This record will remain in the child’s file at our School so we may assist with the allergy care and needs of our student and your patient. If you need to provide further instructions or clarifications, please do so on a separate sheet of paper that will become part of this record and will be kept with this form in the child’s file at Ascension Catholic School.
Child’s Name: ____________________________ Child’s Birth Date:_______________
PART 1 (to be completed by physician)
Allergens:
Please provide a complete list of all events and/or substances that may trigger a severe allergic reaction, (anaphylactic shock) in the child.
____ Bee Sting
____ Other Insect Bite(s): (identify): __________________________________________
____ Animal Fur: (identify): ________________________________________________
____ Food Allergy: (identify all foods that must be avoided): ______________________
________________________________________________________________________
Other: (identify): _________________________________________________________
Symptoms:
Please provide a complete list of all symptoms indicating that the child has come into contact with an allergen and that he or she requires emergency treatment.
____ Shortness of Breath or Difficulty in Breathing
____ Swelling of the Face or Lips
____ Hives
____ Vomiting
____ Diarrhea
____ Other: (explain): _________________________________________________
____ Do not administer medication in the absence of known exposure to allergen.
(explain): ____________________________________________________
Procedures:
Please indicate all steps necessary and the order in which they should be taken.
____ Give Benadryl Elixir, ml orally (Dosage __________)
____ Administer EpiPen, Jr. or ____________________________
____ Call the area’s emergency medical personnel (e.g. 911)
____ Call parent(s)/guardian(s), and child’s physician.
____ Other
(explain): ______________________________________________
Recreational Activities:
1. The child may participate in recreational activities. [ ] Yes [ ] No
2. Activity Restrictions: [ ] None [ ] Some Restrictions
(explain): ________________________________________________
Child’s Physician:
Name: _____________________________________________________
Address: ___________________________________________________
Telephone No. ______________________________________________
Emergency Contact No. _______________________________________
Signature:_______________________________ Date: _______________
PART II (to be completed by Parent(s)/Guardian(s)
Parent(s)/Guardian(s):
Name: _____________________________________________________
Address: ___________________________________________________
Telephone No. ______________________________________________
Emergency Contact No. _______________________________________
____________________________________________________________