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Record of Medicine Administered
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* Indicates required question
Email
*
Your email
Child Name
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Medical condition
*
Your answer
Name of medicine
*
Your answer
Name of person administering medicine
*
Your answer
Date medicine administered
MM
/
DD
/
YYYY
Brief description of why your child takes this medicine, including how often and instructions showing the dosage. The more information you can give us the better equipped we will be to take care of your child.
*
Your answer
Name GP / Doctor
Your answer
Telephone number of GP / Doctor
*
Your answer
I understand that all medicines should be clearly labelled with the child’s name and the name of the medicine and given directly to Kiki or Mark. It is vital that we have the name of the medicine in case of an emergency.
*
Yes
No
If yes, you must provide confirmation/proof from your doctor.
Signature
*
Your answer
Date of signature
*
MM
/
DD
/
YYYY
Send me a copy of my responses.
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