Permission Form - Prescription

Dear Parent/Legal Guardian,

Health services are provided to all students in the Madison Metropolitan School District by school nurses and nurse's assistants. These services are provided to ensure your child's safety and well being during the school day.

Our staff includes many pediatric nurse practitioners licensed by the Wisconsin State Board of Nursing as advanced practice nurse prescribers (APNPs) who are able to diagnose illnesses and prescribe medication if needed. APNPs in the Madison School District can:

• Recommend the appropriate non-prescription treatment for pediculosis (head lice), tinea corporis (ringworm of the body), or minor skin infections and
• Prescribe medication for conjunctivitis (pinkeye), impetigo, otitis externa (swimmer's ear), otitis media (ear infection), scabies, and strep throat.

This is only possible with your written permission and is subject to the availability of an APNP at your child's school. On some days or parts of some days, the APNP may not be available in your child's school. The prescription can be filled at your regular pharmacy. The coverage for the cost of the prescription depends on acceptance of the prescription by your health insurance company. When a prescription is written, notification will be made to your primary care provider.

If you would like to use this service, please complete the bottom of this form and return it to the nurse at your child's school. Copies of the protocols for treatment are available from the nurse in your child's school. A new permission form is required each school year.

Student Name:__________________________ Student Number:________ Grade:_____

Health Insurance:_______________________ Health Care Provider: ____________

We must know if your child has any drug allergies or history of any drug
reactions.  Please list:___________________________________________________

___________________________________________________________________________
 
I give permission for the Advanced Practice Nurse Prescriber to recommend
appropriate non-prescription medication and to prescribe medication in the
situations listed above.

Signature of Parent/Legal Guardian:________________________________________

Date:__________________ School:____________________________________________

Health Information

For more information, contact:
Freddi Adelson, Health Services Coordinator
Madison Metropolitan School District
545 W. Dayton St.
Madison, WI 53703