JHCD-E

ROCHESTER SCHOOL HEALTH SERVICES

Rochester, New Hampshire 03867

SCHOOL ADMINISTRATION BUILDING

62 SOUTH MAIN STREET

TELEPHONE (603) 332-3678

FAX (603) 335-7367

PHYSICIAN STATEMENT

Under the provision of RSA 541-A as of 20 November 1974: when it is found necessary to place a child on medication during the school day, the school must have the following information:

Child's Name:

Diagnosis is:

Dosage:

Time Schedule:

Medication to be taken from (Dates):

Doctor's Signature

A note from the Doctor, containing the above information will be acceptable.

Adoption Date: April 8, 1993