Consent to Administer Medication

Consent to Administer Medication

For prescribed medication to be administered within school hours
Our Medications in School Policy states that staff can administer medication to pupils during school hours.

The school will not give your child medication unless this form has been completed. Therefore please ensure that this form is submitted before your child arrives at school.
Child’s Name*

First NameLast Name
Child's date of birth *

DayMonthYear
Date
Medication Name, as it appears on the label*
Expiry date*

DayMonthYear
Date
Amount sent to school*
Does the medication need to be stored in a fridge?*

YesNo
Date prescribed by a GP*

DayMonthYear
Is this an acute medicine (to take for less than 30 days) or an ongoing medicine (longer than 30 days or repeat prescription)*

Acute (less than 30 days)Ongoing (more than 30 days)To be advised
Name of GP*
GP telephone number
Please enter a valid phone number.
Reason for medication*
Diagnosis and/or brief description of symptoms
Last time medication was given *

DayMonthYear
Date
Hour MinutesAM/PM Option
Dosage to be given*
Eg. 2 tablets, 15 ml, 2 drops, 1 puff etc.
When should medication be given?*

As and when requiredSet times (enter times below)
Time of first dose (if applicable)

Hour Minutes

AM/PM Option
Time of second dose (if applicable)

Hour Minutes

AM/PM Option
Time of third dose (if applicable)

Hour Minutes

AM/PM Option
Time of fourth dose (if applicable)

Hour Minutes

AM/PM Option
Does the medication need to be sent home at the end of the day?*

YesNo
Additional information
ASTHMA INHALERS

Pupils who have been prescribed an inhaler must ensure they bring it to school each day. However, the school has a small supply of spare inhalers which can be used, with your consent, should the child forget their own. (Please note that the inhalers are sanitised between uses).
I consent to my child using a school inhaler if necessary *

YesNoNot applicable
Parent Name *

First NameLast Name
Contact telephone number*
Please enter a valid phone number.
Terms and Conditions
- Medication must be in the original named box/bottle and always with the pharmacy label showing the child’s name, DOB, dose, date and storage instructions.
- A measured medicine spoon / syringe should be supplied with the medication (if applicable).
- Staff must be given all of the information required to insure the well-being of the child.
- Your child should be given at least one dose at home and monitored for any unwanted reactions before sending the medication into school.
- School should be informed immediately if there is a change to this medication.
CONSENT
Agreement to terms and conditions*

I agree to the terms and conditions above and give school staff my consent to administer the above medication, according to the pharmacy instructions provided.
Signature*

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Consent to Administer Medication

ASTHMA INHALERS

Terms and Conditions

CONSENT