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MARIST COLLEGE UPWARD BOUND - INDIVIDUALIZED ORDER FORM 3399 NORTH ROAD POUGHKEEPSIE, NY 12601 TEL: 845-575-3258 FAX: 845-575-3259 INDIVIDUALIZED ORDERS FOR Name: ____________________________________________________ DOB: _______________________ Weight: ________________ The following form must be completed and signed by the child’s physician. If the child will be taking any prescription medication while at camp, the doctor must also complete the reverse side of this form. Camp nurses are only permitted to dispense medications to a child that is listed on this form by the child’s doctor. The Camp Nurse (RN) will call the prescriber, as allowed by HIPAA, if a question arises about the camper and/or the camper’s medication(s). Standard Over the Counter/PRN Medications (the following medications are available in the Infirmary and will be administered at the discretion of a RN, if approval is indicated by the camper’s healthcare provider): Drug Name Tylenol (or generic) Ibuprofen Robitussin (or generic) Pepto-Bismol (or generic) Kaopectate (or generic) Children’s Mylanta (or generic) Route PO (Chewable, elixir, or tabs) PR (suppository) PO (Chewable tabs, suspension, or tabs) PO (Syrup) PO (Liquid, or chewable tabs) PO (Liquid or tabs) PO (Chewable tabs) Sudafed (or generic) PO (Tabs/liquid) Chlorpheniramine PO (Chewable tabs, suspension, or tabs) PO (Chewable, regular tabs) Dramamine/Bonine (or generic) Dimetapp (or generic) PO (Elixir or tabs) Benadryl (or generic) PO/Topical (Elixir, chewable tabs or pills) (Topical ointment) Dosage Indications Per label instructions by age/weight Per label instructions by age/weight Per label instructions by age/weight Per label instructions by age/weight Per label instructions by age/weight Per label instructions by age/weight Per label instructions by age/weight Per label instructions by age/weight Per label instructions by age/weight Per label instructions by age/weight Per label instructions by age/weight Pain or fever Health Care Provider Order Yes No Pain or fever Yes No Cough Yes No Upset stomach, diarrhea Yes No Diarrhea Yes No Upset stomach Yes No Nasal congestion, Eustachian tube congestion Seasonal allergy symptoms Yes No Yes No Motion sickness Yes No Nasal congestion, seasonal allergy symptoms Allergic reactions, (hives, insect bites) Yes No Yes No Comments (continue on other side) Antibiotic Ointment Hydrocortisone Cream Topical Calamine Lotion (or generic) Mentholyptic Cough Lozenges Topical Per label instructions Per label instructions Topical Per label instructions Per label instructions Superficial cuts/abrasions Allergic reactions (contact dermatitis, insect bites) Allergic reactions, (hives, insect bites) Coughing, sore throat Yes No Yes No Yes No Yes No Prescription Medications (Please complete with the patient’s current regimen for both scheduled and PRN medications): Drug Name Route Dosage and Schedule Indications Camper Health Care Provider Order Comments Additional Orders: (As deemed necessary by health care provider to be implemented by a RN) ______________________________________________________________________________________________________________________ _________________________________________________________________________________________________ Camper’s Health Care Provider Name: __________________________________ Phone #: ________________ Type/Print Name: _________________________________________________________________________________ Address: __________________________________________________________ License#: ___________________ Signature: _________________________________________________________ Date: ______________________