Forms

Below is a list of forms that you can print and fill out prior to your office visit.

New Patient Forms:

New Patient Information Sheet

HCSD Medication Authorization Form - Form A - This form covers the prescription medication, inhalers, non-prescription medication (for grades 7-12 only)
HCSD Oral or Inhaled Medication Form - Form B - This form covers oral/miscellaneous and inhaled medication
HCSD Injectable Medication Form - Form C - This form covers injectible medication
HCSD Nebulized Medication Form - Form D - This form covers nebulizer medication
Emergency Care Plan - Food allergy and anaphylaxis emergency care plan

DCSD Medication Authorization Form by School Personnel - Form 5530 F1 - Request for administration of prescription and nonprescription medication by school personnel, not to be used for epinephrine or inhalers
DCSD Student Self-Administration of Nonprescription Medications - Form 5530 F4 (HS/MS) - Request for student to self-administer nonprescription medciation without supervision - High School or Middle School
DCSD Asthma Action Plan and Orders - Form 5530A A F1
DCSD Allergy Emergency Care Plan - Form 5330A E F1 - Allergy and anaphylaxis emergency orders and action plan

CCS Medication Authorization Packet - Packet for students taking medications at school
CCS Asthma Packet - Packet for students with asthma - includes a care plan
CCS Allergy Packet - Packet for students with allergies - includes medication authorization form, epinephrine auto-injection medication authorization form, and special diet order form
Columbus City Schools Medication Forms - All of ther medication forms can be found here.