Medically Prescribed Treatment (Non-Medication) Form — Provider Treatment Order Form | Office of School Health | School Year 2025–2026 Completed Form Examples and Samples
View a filled sample of the Medically Prescribed Treatment (Non-Medication) Form for the 2025–2026 school year. This example of the Office of School Health's Provider Treatment Order Form helps parents and healthcare providers correctly document student treatment needs.
Medically Prescribed Treatment (Non-Medication) Form Example for School Year 2025-2026
How this form was filled:
This is a filled-out sample of the Office of School Health's Provider Treatment Order Form for non-medication treatments for the 2025-2026 school year. The example shows how to document a provider's order for a student with asthma to receive saline nebulizer treatments as needed during school hours, including diagnosis, treatment details, and authorization signatures.
Information used to fill out the document:
- Student Name: Emily Johnson
- Date of Birth: 08/15/2018
- School Name: P.S. 123 Elementary
- School Year: 2025–2026
- Parent/Guardian Name: Sarah Johnson
- Parent Signature Date: 09/06/2025
- Healthcare Provider Name: Dr. Michael Chen, MD
- Provider's Practice: Springfield Pediatrics
- Provider's Phone: 555-123-4567
- Provider Signature Date: 09/05/2025
- Diagnosis: Asthma (J45.20)
- Prescribed Treatment (Non-Medication): Nebulizer treatment with 0.9% Sodium Chloride (Normal Saline)
- Dosage/Amount: One 3mL vial
- Route: Inhalation via nebulizer
- Frequency/Indications for Treatment: As needed (PRN) for persistent coughing, wheezing, or shortness of breath.
- Treatment Start Date: 09/08/2025
- Treatment End Date: 06/26/2026
- Special Instructions: Administer over 10-15 minutes. Student may rest in the nurse's office during treatment. Notify parent/guardian after administration.
What this filled form sample shows:
- Clearly specifies the student's diagnosis and the required non-medication treatment.
- Includes detailed instructions for school staff on when and how to administer the treatment.
- Covers the entire 2025–2026 school year with specific start and end dates.
- Contains properly executed signature and date fields from both the parent/guardian and the prescribing healthcare provider, which is essential for authorization.
Form specifications and details:
| Form Name: | Medically Prescribed Treatment (Non-Medication) Form — Provider Treatment Order Form |
| Issuing Authority: | Office of School Health |
| Applicable School Year: | 2025–2026 |
| Use Case: | In-school saline nebulizer treatment for a student with asthma. |
Created: February 13, 2026 01:27 AM
