2023-2024 School Diabetes Order Form
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2023-2024 School Diabetes Order Form
Patient name:
*
(First, Last)
Date of birth:
*
(mm/dd/yyyy)
If you already have a school order for 2023-2024 and need an order sent for a dose adjustment to your school. Please complete only the needed section. Thank you.
School district:
School name:
*
School fax number:
*
2023-2024 school year grade level:
Insulin delivery
My child takes multiple daily injections by pens
My child uses an insulin pump
If your child uses an insulin pump: please specify which brand
OmniPod
Medtronic
Tandem
What is your emergency injectable Glucagon/Glucagen dose for a severe low blood glucose.
0.5 mg
1.0 mg
Insulin Administration
Please choose one: My child is prescribed:
Apidra U-100
Fiasp U-100
Humalog U-100
Novolog U-100
Other, please specify
Insulin dosing: Breakfast carb ratio
If your child eats breakfast at school, list the number of grams of carbohydrates for each unit.
Insulin Dosing: Lunch carb ratio
List the number of grams of carbohydrates for each unit.
Insulin dosing: Blood glucose correction factor
1 unit per ___ points greater than ___ target
List the number of points
List the target number
School order form completed by:
*
First, last name
Relation to student
Best contact phone number
By checking this box, I attest this order form is correct. I fully understand my child’s provider may make adjustments.
*
You as the parent/caregiver will be required to sign the school order form prior to implementation of the orders for your child.
I agree