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Medicine Permission Form (Long Term)
Staff at Oakmere Primary School cannot give your child medicine unless you complete and return this form.
If more than one medicine is required, please complete another form.
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* Indicates required question
Email
*
Your email
Child's forename
*
Your answer
Child's surname
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Class
*
Nursery
Reception
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Medical condition or illness
*
Your answer
MEDICINE
Medicines must be in their original container/bottle as dispensed by the pharmacy
Name of medicine -
Please put the name of the medicine as described on the container
*
Your answer
Expiry date
*
MM
/
DD
/
YYYY
Dosage required
*
Your answer
Time to be given
*
Your answer
Any other instructions
*
Your answer
Number of tablets/quantity of medicine given
*
Your answer
Emergency Contact Details
Parent/Carer's name
*
Your answer
Daytime telephone number
*
Your answer
Relationship to child
*
Your answer
Name and telephone number of GP
*
Your answer
Date this form was completed
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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