Medication Authority Form

Medication Authority Form

For participants with asthma, anaphylaxis, diabetes or epilepsy an Emergency Action Plan is required. Please note, MDS will only administer medication outlined in this authority. This authority will remain in effect unless withdrawn in writing. This authorisation may be withdrawn at any time.
Participant Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState

Postcode
Phone Number
Phone Number*

Area CodePhone Number
Medical Condition/s*
Review Date*

DayMonthYear

Medication/s to be Administered*

	Name of Medication	Dosage	Time/s to be Taken	Dates/Days to be Administered (Start & End or Ongoing?)	Supervision Required (no - self administered/ Remind/Administer/Observe/ Assist)
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

Administering Instructions (please outline specific administering instructions):*
Storage instructions? Please indicate if there are any specific storage instructions for any medication. *
Self Administration:

Self-management should be agreed to by the participant and their carer/guardian, MDS and the participant's medical/health practitioner. Please note, medication will be stored by MDS at Benno House. Please describe what supervision or assistance is required by the participant when taking medication.
Administering Instructions: (Please outline specific administering instructions) Parent/guardian/health professional will be contacted/alerted in the instance of medication refusal.
Emergency Action Plan - Does the participant have asthma, epilepsy, seizures, diabetes or anaphylaxis. If yes, an emergency action plan is required. Upload a copy below.*

YesNo
Upload a copy of the Emergency Action Plan if answered yes above.

Cancelof
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We collect personal and health information to plan and support the health care needs of our participants. Information collected will be used and disclosed in accordance with our privacy policy and relevant legislation.
Authorisation to administer medication in accordance with this form:

By signing you are agreeing to the following:
- I have the authority to sign this form.
- I declare the information in this form has been completed by me, and is true and correct.
Name of authorised person:

First NameLast Name
Relationship to the participant:
Phone Number

Phone Number
Your Address

Street Address

City

Postcode
Signature

Clear
Date

DayMonthYear
Date
Should be Empty: