Administration of Medicines Request Form

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Administration of Medicines Request Form - Year 7 Intake 2021

Staff will not administer medicines to your child unless this form is completed. Medicines MUST be supplied in their original packaging with the information leaflet and the dispensing label attached.

Email *

Name of Student *

Date of Birth *

YYYY

Medical condition or illness *

Name/Type of medicine (as described on the packaging) *

Date dispensed for prescription medicines or date commenced for over counter medicines *

YYYY

Expiry date *

YYYY

Dosage instructions *

Are there any side effects that the school needs to know about? *

Can the student self administer the medication? *

Yes

What are the procedures to be taken in the case of an emergency? *

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