Medication Administration Form
For prescribed medication to be administered. All medication must be in prescription bottle with child's first and last name on it.
Childs Name
*
Childs date of birth
*
Medication Name, as it appears on the label
Dosage to be administered as appears on bottle
Last time medication was given
Time to administer
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Hour
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Minutes
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PM
AM/PM Option
Time time to administer if more than once
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12
:
Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Time to administer if more than once
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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
Medication must be All medication should be in original named box/bottle and always labelled with the child’s name, DOB, Dose and date. (dispensed from the pharmacy). Please supply a measured medicine spoon/syringe. Please give staff all the information required to insure 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. Our day is 24hrs day so 3 times/day means every 8hrs, unless stated by the GP. Staff will log in medication administration in Brighthweel.
Agreement to terms and conditions
I agree to the terms and conditions above
Parent First and Last Name
Date that consent given
*
Parent Signature
Submit
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