Medication Form

REQUEST FOR ADMINISTRATION OF MEDICATION IN SCHOOL

All medication must be given to the school office in the original packaging and a separate form completed for each medicine

Non-prescribed medication will not be accepted unless prior agreement has been given by the Headteacher

Name of Child*

Class*

Date of Birth*

Date

Medical condition or illness*

Name/type of medicine (as described on the container)*

Date Dispensed*

Date

Expiry date*

Date

Dosage and method*

When to be given*

Any side effects that the school needs to know about*

Self administration?*

YesNo

Is there a Care Plan in place?*

YesNo

Asthma (please tick boxes as appropriate)

My child's reliever inhaler should be held in the classroom to be administered as requiredMy child has my permission to carry his/her reliever inhaler for self-administration and I understand that it is my child's responsibility to notify their teacher or the school office when it has been used so it can be noted on his/her Medication Record.

In accordance with the London's Schools' guide for the care of children and young people with asthma, we are required to have an Asthma Card for all children diagnosed with this condition. Forms are available from the office and on the website. Please arrange for this to be signed by your child's doctor or nurse and returned

We have salbutamol inhalers and spacers in school for emergency situations. Please indicate below if you are happy for this to be administered to your child if necessary.

I do not give consentI give consent

Emergency Auto-Injector Adrenaline pens

We have 2 auto-injector adrenaline pens for emergency use. Please be aware that these may not always bethe same brand as prescribed by your child's practitioner. Please indicate below if you are happy for these to be administered to your child if necessary.

I do not give consentI give consent

Contact name and telephone number*

GP Surgery and telephone number*

The obove information is, to the best of my knowledge, accurate at the time of writing and I give consent to school staff administering medicine in accordance with the school policy. / will inform the school immediately, in writing, if there is any change in dosage or frequency or if the medication is stopped.

Parent's signature*

Print name*

Date*

Date

REGULAR MEDICATION WILL BE SENT HOME AT THE END OF THE SUMMER TERM A NEW FORM IS REQUIRED EACH ACADEMIC YEAR