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Medication Authorization Form for Life-Threatening Allergy.pdf
Medication Authorization Form for Life-Threatening Allergy
Handle: Document-81256
Owner: Johnson, Kari (User-3179, 11095:EVERETT)DS
Wednesday, August 24, 2016 12:49:02 PM PDT
Wednesday, May 3, 2023 06:15:31 PM PDT
Modified By: Johnson, Kari (User-3179, 11095:EVERETT)DS
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  • MEDICATION AUTHORIZATION ORDER FOR
LIFE-THREATENING ALLERGYStudent name: DOB:School: Grade:THIS PORTION TO BE COMPLETED BY LICENSED HEALTHCARE PROVIDER (LHCP)Life-threatening severe allergy to:For the following symptoms Give the following medicationsFor individual symptoms, if multiple medications are selected, Epinephrine will always be given first.
  • ❑ Albuterol Oral Inhaler puffs by mouth ❑ Other:
Inhale puffs orally once.
  • ❑ Inhale puffs minutes prior to physical activity prn.
  • LHCP SIGNATURE/INFORMATI...
Allowed
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Life-Threatening Allergy Authorization Form.pdf
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Appears In: Medication Authorization Forms
Preferred Version: Medication Authorization Form for Life-Threatening Allergy.pdf