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Get Lausd Medication Form

Lth Care Provider) Student name Last First Sex Name of medication Birth date School Date of prescription Time schedule at school Dosage prescribed Dose form Route (Tablet, liquid, injection, inhalant, etc.) Purpose of medication or diagnosis Licensed Health Care Provider s Recommendations (Check where applicable) The medication may have adverse side effects (explain) Special instructions and/or comments The student for whom this medication is prescribed is under my care. Print name.

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