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Medicine Permission Form (Short Term)
Staff at Oakmere Primary School cannot give your child medicine unless you complete and return this form.
Medicines must be in the original container as dispensed by the pharmacy
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
Willow
Pine
Birch
Rowan
Poplar
Chestnut
Elder
Cedar
Hawthorn
Blue Oak
Red Oak
Other:
Medical condition or illness requiring medication
*
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
Date medication provided by parent
*
MM
/
DD
/
YYYY
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
Are there any side effects we need to be aware of?
*
Yes
No
Known side effects
Your answer
Can the child administer the medication in their own.
(Children will always be supervised)
*
Yes
No
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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