JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Pupil Medication Request Form
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Child's First Name
*
Your answer
Child's Surname
*
Your answer
Class
*
Choose
YN
RB
RM
RP
1B
1P
1MH
2J
2S
2W
3J
3S
3K
4G
4V
4W
5O
5B
5T
6L
6DA
6C
6B
Parent/Carer Name
*
Your answer
Contact Telephone Number
*
Your answer
Condition or Illness
*
Your answer
G.P. Name and Phone number
*
Your answer
Please tick the appropriate statement below
*
My child will be responsible for the self administration of medicines as directed. (Medicines will still be kept in the School Office)
I agree to a member of staff administering medicines/providing treatment to me child as directed below
Required
Name of Medicine (medication will not be accepted unless it is in the labelled packaging from the pharmacy).
*
Your answer
Dose
*
Your answer
Time Required/Frequency
*
Your answer
If medicine has been administered within the last 24 hours, please state time:
Time
:
AM
PM
Completion date of course (school year end if ongoing)
*
MM
/
DD
/
YYYY
Expiry date of medicine
*
MM
/
DD
/
YYYY
Special Instructions
Your answer
Allergies
Your answer
Is your child currently taking any other medicines? If so, please give details:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Stamford Green Primary School.
Report Abuse
Forms
