IBUPROFEN

Plymouth Public Schools

Parent/Guardian Consent for Medication Administration

(Page 1 of 2)
Student: _______________________________________
Male

Female

Date of Birth: ______________ Grade: ____________ Date of Consent: __________

My son/daughter is known to have the following allergies:

Diagnosis (if not in violation of confidentiality):

______________________________________________________________________
1. I request and give permission to the school nurse to give my son/daughter:
Medication: Ibuprofen

Dosage: ___________________

Route:

Time of Day:

Oral

Prescribed by:
2. I give permission to the school nurse to share with appropriate school personnel
information relative to the prescribed medicine administration as s/he determines
necessary for my childs health and safety.

Yes

No
3. I understand that in the event of a field trip, this medication administration plan may
need to be adjusted and I will do the following:

Call the school nurse prior to the field trip to discuss the plan for
administering this medication

This medication may be withheld (not given) on the day of the field trip.
4. I understand that I may retrieve the medicine from the school at any time, and that
the medicine will be destroyed if it is not picked up within one week following the
termination of the order or the last day of school.
Parent/Guardian Signature: ___________________________ Date: _____________

IBUPROFEN
Student Name:

Plymouth Public Schools

Parent/Guardian Consent for Medication Administration

(Page 2 of 2)
MEDICATION ADMINISTRATION PLAN (To be completed by the School Nurse)
Medication: IBUPROFEN (Advil, Motrin, Excedrin) Duration of Medication:
Date Ordered:

Expiration Date of Medication:

Time to be Given:

Quantity Received:

Contraindications/Side Effects: Hypersensitivity to drugs, to NSAIDs and in those with nasal polyps, or
bronchospastic reaction to aspirin or other NSAIDS. Contraindicated for post op pain after CABG procedure
and in pregnancy. Use cautiously in patients with GI disorders, hx of peptic ulcer disease, hepatic or renal
disease, cardiac decompensation, hypertension, asthma, or intrinsic coagulation defects. May mask signs and
symptoms of infection. May cause blurred or diminished vision and changes in color vision. Full antiinflammatory effects may take 1-2 weeks.

Onset/Peak/Duration:

O: Variable

P 1-2 hours

Refrigeration:

Yes

 No

IHCP Indicated:

Yes

No

Original MD order received:

Yes

No

Entered into Health Office Computerized Database :

D: 4-6 hours

Medication Administration record completed and placed in medication book:

School Nurse Signature: _________________________________Date:

Medication may be given 30 minutes before or after scheduled time; or at an alternate time if
school schedule or activities change.
Parent form med consent_Ibuprofen.doc
Created July 12, 2011