Long Term Medicine for Inhaler Form
This form is only to be filled in for inhaler that will be administered in nursery for a period of time greater than 1 week. The form must be filled in 24hrs before the child attends and you must have received acknowledgement that we have accepted the form before you bring in the medicine. The medicine must be brought into nursery in a clear plastic container with a lid. It must be labeled with the child's full name and DOB and the expiration date of the medicine. The medicine must have a pharmacists label on with the child's name clearly visible. The medicine must new and unopened and will be kept in nursery at all times. If this procedure is not followed we will not accept the medicine into nursery.
Child's Name
*
First Name
Last Name
Child's Date OF Birth
*
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Day
-
Month
Year
Date
Date medicine was prescribed
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Day
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Month
Year
Date
Date medicine is to start in nursery
*
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Day
-
Month
Year
Date
Name of medicine
*
Name of Doctor who prescribed medicine
*
Reason for medicine?
*
How should the medicine be administered?
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How much medicine be administered?
*
When should the medicine be administered? Please be specific about the symptoms your child will display
*
What are the possible side effects we should be aware of?
*
How should the medicine be stored?
*
By signing this form I am giving 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. I consent to Peekaboo Childcare making the decision on when to admisiter this medicine based on the symptoms I have detailed above.
Parental consent given
Signature
Name of parent signing
First Name
Last Name
Date signed
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Day
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Month
Year
Date
Submit
Should be Empty: