Long Term Medicine Form
This form is to be used for medicines that will be administered in nursery over more than 1 week. We must have this form filled in and returned at least 24 hours before the child comes to nursery and you must have received an acknowledgment that we have received this before bringing in the medicine. The medicine must be brought into nursery in a sealed plastic container clearly labeled with the child's name, date of birth and the expiration date of the medicine. If this procedure is not followed we will be unable to administer the medicine.
Child's Name
*
Child's DOB
*
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Month
-
Day
Year
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Child's Key group
*
Starfish
Sharks
Seahorses
Turtles
Date medicine was prescribed
*
-
Month
-
Day
Year
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Date the medicine is to start in nursery
*
-
Month
-
Day
Year
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Expiration date of medicine
*
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Month
-
Day
Year
Date
Name of medicine
*
Name of doctor who prescribed the medicine
*
Reason for medicine
*
How should the medicine be administered?
How much medicine should be given?
When should the medicine be given? Please give exact times of the day.
*
What are the possible side effects we need to look out for? are the possible side effects we need to look our for? You need to find this in the information leaflet and write the side effects here. Please do not write NONE or UNKNOWN
*
How should the medicine be stored?
I give my consent for the staff at Peekaboo Childcare to administer this medicine as instructed above and I declare that the information on this form is correct and that this medicine is being given appropriately as directed by a doctor or medical professional.
*
PARENTAL CONSENT
Signature
Parent name
*
Date form was submitted
*
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Month
-
Day
Year
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Submit
Should be Empty: