Medicine Administering Form

Name of child:* Date of birth:* Form Group:* Medical condition or illness:*

Medicine

Name/type of medicine: (as described on the container)* Expiry date:* Dosage and method:* Timing:* Special precautions/other instructions:* Are there any side effects that the school/setting needs to know about?*

Self-administration:*YesNo

Procedures to take in an emergency:*

NB: Medicines must be in the original container as dispensed by the pharmacy.

Contact Details

Name:* Daytime telephone number:* Relationship to child:* Address:*

The information above is, to the best of my knowledge, accurate at the time of writing and I give consent to school/setting staff administering medicine in accordance with the school policy.
I also consent to the school contacting the School Nurse Team if necessary.
I will inform the school/setting immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped.