Riverside USD | E 5141.33 Students
DEPARTMENT OF HEALTH SERVICES
HEAD LICE TREATMENT FORM
The head lice medication _____________________________ is to be used to treat ________________________________.
School _________________________________________ Date of Birth ________________
Please answer the following questions:
1. Has your child had previous reactions to any head lice medications? ______________
2. Is your child allergic to Chrysanthemum flowers? _______ or Ragweed? ______
3. Does your child have asthma? ____________________________________________
I have received and understand the instructions regarding use of the head lice medication. I request that the Riverside Unified School District provide the head lice medication. I further agree to hold the Riverside Unified School District and its employees harmless in the provision of this head lice medication.
Signature of Nurse Signature of Parent/Guardian
Instructions for Use of Head Lice Medication
The head lice medication ________________________________ is to be used to treat _____________________________________.
Do not use the medication on any child under the age of 2 years.
Do not use the medication on any woman who is pregnant or breast feeding.
Keep this medication and all other medications stored in a closed cupboard up out of the reach of children.
The medication is for use on the hair only and may be harmful if swallowed.
If the medication is swallowed,
immediately call the
POISON CONTROL CENTER
1-800-544-4044 (24 hour)
Avoid contact with eyes, if any medication gets into the eyes, flush eyes with water immediately and consult your physician.
If your child develops breathing difficulties or an asthmatic episode, consult a physician immediately.
If your child develops itching, redness, swelling or stinging of the scalp, stop using the medication. Rinse any medication off hair and scalp with water, consult your physician.
Read and follow the directions on the medication.
If you have any questions, call the Central Registration Center, Health Center at 951-274-4213 ext. 83027 during normal business hours.
Exhibit RIVERSIDE UNIFIED SCHOOL DISTRICT
version: June 26, 2018 Riverside, California