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MEDICATION ORDER FORM 2016-17. For Prescription and Over-the-Counter Medication. Physician Please Note: This form is for one child and one drug only. This order form is required EVERY TIME a written prescription from your medical provider is Medication delivery may take up to 21 days from the date you mail your order. We now accept electronic prescriptions directly from your doctor. PRESCRIPTION MEDICATION FORM. OF CUDAHY. PHYSICIAN or PRESCRIBER ORDER. Student Name: Date of Birth: Grade: Student's School: (Check One). Physician Medication Order Form prescription(s), complete section A only and remember to fax it to 1-888-870-2808 or mail us the written prescriptions along Prescription Medication Form/Physician's Order (To Be Completed By This student may carry & self administer medication* _________Physician Initial PHYSICIAN'S MEDICATION ORDER FORM The order must match the prescription label. Verbal order must be followed by a signed order within 1 day. New Prescription Fax Order Form. Please fill out Section 1, then have your physician fill out Section 2 and FAX it to 1-800-491-7997. Medication Allergies:. Medication Form/Physician's Order (To Be Completed by Physician/Authorized Health Care The first dose of any new prescription must be given at home. 3. Not for CII prescriptions 0 90-day supply, when appropriate. Allergies: Incomplete forms will cause a delay in processing. Indicate the number of medications on this fax. When applicable PRINT Supervising Physician name here ^. / /. In order for a brand name product to be dispensed, the prescriber must handwrite. Use this form to order a new mail service prescription by fax from the prescribing physician's office. Member This fax is void unless received directly from physician's office. To contact Over-the-counter/herbal medications taken regularly:.
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