Epi-pen or Other Life Saving Medication

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EPI-PEN OR OTHER LIFE SAVING MEDICATION

If your child is prescribed emergency, life saving medication such as an epi-pen please bring the medication in to school in the original container with the prescription label attached. You will must complete this form before we can administer any medication. Please note we cannot administer other medication or over the counter medications including cough lozenges and painkillers.
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Pupil Name* This field is required.
First Name
Last Name
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Class pupil is in* This field is required.
Nursery
Reception
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Note: Medicines must be the original container as dispensed by the pharmacy with the child's name on.

If more than one medicine is to be given, a seperate for should be completed for each one.
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Name of medication and strength* This field is required.e.g. EPIPEN (epinephrine injection, USP) 0.3 mg
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Expiry Date of Medication* This field is required.e.g. 01-10-2022
Date
Day
Month
Year
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Dose to be given and how often* This field is required.
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Any other instructions/ special precautions* This field is required.Please write NONE if no other instructions.
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Name of Doctor and and Surgery* This field is required.
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The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school/setting staff administering medicine in accordance with the school/setting policy.

I will inform the school/setting immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped.
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Parent's Name* This field is required.
First Name
Last Name
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Signature* This field is required.
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