Medical Administration Form

Details of Pupil

Pupil Surname *

Forename(s) *

Address *

Date of Birth *

Boy or Girl *

Class *

Other medications taken by the child *

Allergies *

Name/Type of Medication (as described on the container) *

Add a photo of the prescription box label (showing dosage and patient name) *

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Date dispensed: *

Expiry date *

Full Directions for use (Dosage and method) *

Timing *

Special precautions *

Are there any side effects that the School needs to know about *

I understand that I must deliver the medicine personally to (agreed staff member name) *

I accept that this is a service, which the school is not obliged to undertake. I understand that I must notify the school of any changes in writing *

Yes

Parent Name *

Parent Email address *

Date *

Please upload a copy of your signature *

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Phone