Medication Permission Form

Child's Name *

Form *

Condition / Illness *

I give my permission for my child to receive:

Medication Name *

Medication must be in the original packaging as dispensed by the pharmacy, and we will not exceed the dose stated on the packaging/patient information leaflet unless advised by a doctor’s note.

Please note we will only administer paracetamol/ibrupofen for a maximum of 3 consecutive days unless provided with a doctor’s note.

Dose *

Time(s) *

Date from *

Number of days required *

Can your child self administer the medication? *

Yes

Please detail any special precautions or side effects: *

Contact Details

Full name: *

Relationship to the child: *

Emergency Contact Number *

Doctor’s name and telephone number: *

Any other comments

1. I confirm that I give consent for my child to receive the above medication at school at the times specified.
2. I understand that medications must be handed by a responsible person to a member of staff within the school. *

Yes

FOR OFFICE USE ONLY

Medication Given (date, dose and time):

[Tick this box to confirm submission with X answers blank]

Please leave the next box blank or your submission will not be accepted: