Medication Administration Form
For prescribed medication to be administered at nursery
Childs Name
Childs date of birth
Medication Name, as it appears on the label
Dosage to be administered
Last time medication was given
Time to administer
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Hour
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10
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40
50
Minutes
AM
PM
AM/PM Option
Time to administer if more than once
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Time to administer if more than once
1
2
3
4
5
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10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date prescribed by a doctor
Reason for medication
Additional information
Terms and Conditions
All medication should be in original named box / bottle andAlways labelled with the child’s name, DOB, Dose and date. (dispenced from the pharmacy). Please supply a measured medicine spoon / syringe. Please give staff all the information required to ensure the well-being of the child. At least one dose of the medication has already been administered and my child has not suffered any unwanted reactions. All forms should have clear and specific Reasons, Signs & symptoms. Nuresery classes the term ‘a day’ as a 24 hour period. Therefore when described on the label - 3 times a day means every 8hrs, unless stated by the GP. Staff will log in any medication administration on Famly.
Agreement to terms and conditions
I agree to the terms and conditions above
Parent giving consent
Date that consent given
Parent Email
example@example.com
Submit
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