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Medicine Consent Form
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* Indicates required question
PUPIL DETAILS: Child's full name
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Your answer
Child's class:
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Your answer
Date of birth
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Your answer
Reason for medication (optional)
Your answer
MEDICATION DETAILS: Name of medication (as described on the container)
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Your answer
Date dispensed:
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Your answer
Dosage and amount
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Your answer
Time to be given:
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Your answer
Method
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oral
inhalation
other- please specify
Required
Expiry date of medication
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Your answer
Is the medication to be self administered?
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Yes
No
Required
CONTACT DETAILS- Name
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Your answer
Relationship to student
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Your answer
Contact address
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Your answer
Contact phone number:
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Your answer
PARENT CONSENT: The above information is, to the best of my knowledge, accurate at the time of writing and I give my consent to Academy staff administering medicine in accordance with the Trust's policy.
I will notify the Academy immediately if there is any change to the dosage or frequency of the medication or if the medication is stopped. I understand that the medication must be delivered by a responsible adult to an authorised/ appointed person in the Academy and accept that this is a service that the Academy is not obliged to undertake.
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Please tick the box to indicate consent
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