Medication Consent Form

Medication Consent Form
This Medication Consent Form provides detailed information about the medications you require support with the type of support and consent for Mildura Disability Support Services staff to assist.

Mildura Disability Support Services ensures all participants have current, accurate and reliable records of medication assistance. This is to support the safe management of medication in the community and at home.
Participant Name
Date of Birth

MonthDayYear
Date
Address
Medication Details:
Date Medication Listed
Type of Medication
Name/Details
Dosage
Prompt/Remind
Assist (open packet)
Administer/Apply
I, (Participant/Authorised Representative), hereby give permission and my full consent for Mildura Disability Support Services staff to assist with medication management to the Participant as detailed above.

In the event additional medications are required to be administered or applied, a new Medication Consent Form will be completed.

I acknowledge that should I refuse to take the medications listed above or choose to administer my own medications, I do so at my own risk and that staff may notify my medical practitioner.
Participant/Authorised Representative Name:
Participant/Authorised Representative Signature:
Mildura Disability Support Services I Medication Consent Form
The Consenting Party agrees to allow the Mildura Disability Support Services staff who are appropriately trained and qualified to carry out the above medication support or assistance, as per the pharmacist's/medical practitioners instructions and on the medication packaging.
Participant/Consenting Party Signature

Clear
Participant/Consenting Party Name:
Date

MonthDayYear
Date
Manager/Supervisor Name
Manager/Supervisor Signature

Clear
Date

MonthDayYear
Date
Should be Empty: