Wyoming Seminary Non-prescription Medication Consent
The following over-the-counter medications are kept in the nurse’s office for dispensing by the school nurse on an as needed basis, for relief of short-term complaints: ** The lowest effective dose will be used**
Acetaminophen (Tylenol) 325mg.-1000 mg. every 4 hours. Not to exceed 4000 mg. in 24 hours unless
Ibuprofin ( Advil/Motrin ) 200mg.-600mg. Every 6 hours. Not to exceed 1200 mg. in 24 hours unless
Naproxen sodium ( Aleve ) 220mg.-440mg. every 12 hours. Not to exceed 660mg. in 24 hours.
Advil Cold Medicine 1-2 tablets every 6 hours. Not to exceed 6 tablets in 24 hours.
Tylenol Allergy/Sinus Medication 1-2 tablets every 6 hours. Not to exceed 8 tablets in 24 hours.
Diphenhydramine Hydrochloride ( Benadryl ) 25mg.–50mg. every 6 hours not to exceed 300mg. in 24 hours.
Pseudoephedrine ( Sudafed ) 30mg-60 mg. every 6 hours. Not to exceed 240mg. in 24 hours.
Maalox/Tums Chewable antacids 1-2 tablets twice daily. Not to exceed 8 tablets in 24 hours.
Immodium A-D follow package directions.
Pepto Bismol 30ml.(2 tbsp.) repeat every 1/2 hour – 1 hour, to a maximum of 8 doses in 24 hours.
Excedrin – 1-2 tablets every 6 hours, not to exceed 8 tablets in 24 hours.
I give my permission for the school nurse to dispense medication as needed.
Parent Signature ______________________________________ Date_____________________ Prescription Medications
All prescription medications must be reported to the Health Services Office. The school nurse will de- termine which medications may be in the possession of the student or stored in dormitory rooms. No student may keep Schedule(C III) medication (Codeine, Percocet, Percodan, etc.) or (C II) controlled medication (Ritalin, Adderall, Concerta, etc.) without permission from the school nurse.
All controlled medications will be locked in the Health Office and dispensed on a weekly basis or as needed according to the prescription.
Any student in violation of this policy will be reported to the Dean of Students and may be subject to No medication will be given without seeing the student first. If a resident student is too sick to come to the Health Office the nurse will see the student in the dormitory. Medication will only be dispensed to the ill or injured student, not to a friend or roommate to be given to the student.
Faculty members and dorm parents may dispense medication, approved by the nurse, if they feel comfortable doing so. No faculty member will be required to dispense medication at any time.
Please list all current prescription medications including dose and frequency:______________________________________________________________________________________ ______________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Yes _____________________________________________________________________________________

Source: http://www.wyomingseminary.org/uploaded/upper_school/documents/forms/non_prescrip_for_web.pdf


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