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Short-Term Care Plan Form
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* Indicates required question
Email
*
Your email
Student's Name
*
Your answer
Medication for?
*
Your answer
Medication Name
*
Your answer
When medication course is due to end
*
MM
/
DD
/
YYYY
Self-Administration
*
Yes
No
Dosage of Medication
Your answer
Times to be administered
*
Time
:
AM
PM
Times to be administered
Time
:
AM
PM
Times to be administered
*
Time
:
AM
PM
Medication Expiry Date
*
MM
/
DD
/
YYYY
Date Medication(s) dispended by pharmacy
*
MM
/
DD
/
YYYY
Procedures to take in an emergency (if applicable)
Your answer
I consent to The Cottesloe Medical Team administering my child's medication
*
Yes
Required
Parent Name
*
Your answer
Email Address
*
Your answer
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