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Pupil Medication Form
If you child needs to take medication in school, please complete this form. This can be for regular medication, like inhalers, and short term medication, like antibiotics.
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* Indicates required question
Email
*
Your email
Child's full name:
*
Your answer
Child's class:
*
Your answer
Condition the medication is treating:
*
Your answer
Medication name:
*
Your answer
Dosage required:
*
Your answer
Has this medication been prescribed by a doctor?
*
Yes
No
Date of medication to be administered from:
*
MM
/
DD
/
YYYY
Is this medication ongoing or until a specific date:
*
Until a specific date (short term - please provide a date in the next question)
Ongoing until further notice. Please notify us if this changes and leave the next question blank.
Date medication is given until:
MM
/
DD
/
YYYY
Time/s to be given:
*
Your answer
Any other information to be aware of:
If the medication needs to be give with a drink, snack etc, please put this information here:
Your answer
Name of parent/carer completing this form:
*
By completing this form I authorise the administration of the above medicine to be given at the time stated.
Your answer
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Ashford Park Primary School.
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