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inhaler form 26-27

personas/family-organizer/files/documents/nora-inhaler-form.pdf
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                                                                                                                  School Clinic
                                                                                                          2200 Larkspur Trace
                                                                                                         Westerville, OH 43081

Larkspur Middle School                                                                                         (614) 555-0152
                                                                                                          larkspurms.example



Authorization for a Student to Carry and Use an Asthma Inhaler, 2026-2027
A new form is needed for each school year. Return it to the school clinic or fax it to (614) 555-0140.

 STUDENT
 STUDENT NAME                              DATE OF BIRTH                             GRADE
 Nora E. Adeyemi                           09/21/2014                                7
 STUDENT ID                                KNOWN ALLERGIES
 3204417                                   Amoxicillin

 PRESCRIBER'S ORDER
 MEDICATION                                DOSE                                      WHEN
 Albuterol HFA 90 mcg per                  2 puffs                                   15 minutes before
 puff, with spacer                                                                   exercise; every 4 to 6
                                                                                     hours as needed for
                                                                                     cough or wheeze
 START DATE                                END DATE                                  STUDENT MAY CARRY AND SELF-ADMINISTER
 08/20/2026                                05/28/2027                                YES
 IF NO BETTER AFTER TWO DOSES              PRESCRIBER                                PRESCRIBER SIGNATURE AND DATE
 Call parent. Call 911 if
 in distress
                                           Imani Fairweather, MD
                                                                                     I. Fairweather
                                                                                     MD
                                                                                     08/20/2026

 PARENT OR GUARDIAN
 NAME                                      DAYTIME PHONE                             BACKUP INHALER KEPT IN THE CLINIC
 Leah Brandvold                            (614) 555-0137                            None provided
 SIGNATURE AND DATE


 Leah Brandvold
 08/20/2026

For clinic use: received 08/24/2026, Y. Trevino RN.

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Record

inhaler form 26-27 Document · saved Aug 20, 2026

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The record values this file is made from: the ones its text names with {{record.field}}, and the fields its template reads. A value here is in the file's source; whether it is readable depends on the look.

ValueNow
larkspur-middle.phone 6145550152
larkspur-middle.fax 6145550140
nora.date_of_birth 2014-09-21

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Planted

mismatch Whether Nora is allergic to amoxicillin. Her chart has said so since a rash in 2017, and the immunization record and this year's inhaler form repeat it. In August 2026 the pediatrician said the rash may have been the virus and offered testing; nothing was booked. Nothing settles it. Forms should keep listing it.

only_in_file The orthodontist's terms (a replacement retainer is $175, a missed appointment $40, the insurance figure is an estimate) are only in the contract. The lien release letter says what is left to do: take it and the title to a title office, and tell the insurer to drop the credit union as loss payee; nothing shows either was done. The guardian named for the children (Maren, alternate Tunde, unsettled) is only in an unsigned draft and has no effect. That Nora carries her own inhaler and the clinic has no spare is only on the school form. The 2025 mortgage interest ($9,123.12) and Leah's wages are only on the tax forms.

attachments.yaml 
record: doc-nora-inhaler-form
template: document
style: form
org:
  name: Larkspur Middle School
  lines:
  - School Clinic
  - 2200 Larkspur Trace
  - Westerville, OH 43081
  phone: '{{larkspur-middle.phone}}'
  web: larkspurms.example
  color: '#4a2f6b'
title: Authorization for a Student to Carry and Use an Asthma Inhaler, 2026-2027
body: 'A new form is needed for each school year. Return it to the school clinic or fax it to {{larkspur-middle.fax|phone}}.


  | Student | |

  |---|---|

  | Student name | Nora E. Adeyemi |

  | Date of birth | {{nora.date_of_birth|mdy}} |

  | Grade | 7 |

  | Student ID | 3204417 |

  | Known allergies | Amoxicillin |


  | Prescriber''s order | |

  |---|---|

  | Medication | Albuterol HFA 90 mcg per puff, with spacer |

  | Dose | 2 puffs |

  | When | 15 minutes before exercise; every 4 to 6 hours as needed for cough or wheeze |

  | Start date | 08/20/2026 |

  | End date | 05/28/2027 |

  | Student may carry and self-administer | YES |

  | If no better after two doses | Call parent. Call 911 if in distress |

  | Prescriber | Imani Fairweather, MD |

  | Prescriber signature and date | <span class="sig">I. Fairweather MD</span> 08/20/2026 |


  | Parent or guardian | |

  |---|---|

  | Name | Leah Brandvold |

  | Daytime phone | (614) 555-0137 |

  | Backup inhaler kept in the clinic | None provided |

  | Signature and date | <span class="sig">Leah Brandvold</span> 08/20/2026 |


  For clinic use: received 08/24/2026, Y. Trevino RN.

  '