Specific Health Care Procedures Authorization Form - fcps 2026

The document is a health care procedures authorization form from the Fairfax County Health Department, designed for parents to complete for their child. It includes sections for student information, physician approval of specific medical procedures, and parental consent for school staff to administer these procedures. The form emphasizes the need for proper authorization and outlines the responsibilities of both parents and physicians in ensuring the student's health care needs are met at school.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out Part 1, where you will enter the student's name, sex, home phone number, date of birth, grade, and school year. Ensure all fields are completed accurately.
In Part 2, the physician must provide details about the specific procedure. Enter the physical condition and name of the procedure. Select one of the approval options regarding the standardized procedure.
Document any precautions or possible adverse reactions related to the procedure. Specify when and how long the procedure will be administered at school.
If medication is involved, ensure to complete the Medication Authorization form. Indicate whether the student is allowed to self-administer the procedure.
Finally, in Part 3, have a parent or guardian complete and sign to acknowledge understanding and permission for school staff to assist with medication or procedures as outlined.

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