Health Care Plan
This online form is to be used to document all of your Child's health care conditions that may require treatment, including emergencies, whilst at The Little Lane Nursery.
Your Child's Full Name
*
First Name
Last Name
Your Child's Date of Birth
*
-
Day
-
Month
Year
Date
Medical Condition
Please provide details of the medical condition your Child has:
Condition being treated:
*
Please describe what an emergency situation looks like or an event when treatment would be required - including symptoms to look out for:
*
What care is involved day to day? Please provide details:
*
Treatment plan - please describe the treatment plan:
*
Medical Professional
Please provide details of the medical professional your Child is under the care:
Medical Professionals Name
*
Salutation
First Name
Last Name
Profession (i.e. rheumatologist, paediatrician etc)
*
Contact Phone Number
*
-
Area Code
Phone Number
Medication
Please provide details of any medication your Child has been prescribed in relation to this condition:
Does your child have medication prescribed?
*
Yes
No
Name of current medication(s) and dose(s) to be administered:
*
Any further information about medication(s):
*
Copy of current medication prescription from Medical Professional (for example a photo of current medication prescription). Without confirmation of a current prescription, we will be unable to administer medication.
*
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Emergency Contact Details
In the event of an emergency, please provide the primary and secondary emergency contact details below
Primary Contact - Name
*
Salutation
First Name
Last Name
Primary Contact - Relation to Child
*
Primary Contact - Phone Number
*
-
Area Code
Phone Number
Secondary Contact - Name
*
Salutation
First Name
Last Name
Secondary Contact - Relation to Child
*
Secondary Contact - Phone number
*
-
Area Code
Phone Number
Any additional information - please use this section to provide any details not covered in the previous sections.
Parent(s) Signature
Parent 1 Signature
*
Parent 1 Full Name
*
Salutation
First Name
Last Name
Date
*
-
Day
-
Month
Year
Date
Parent 2 Signature
Parent 2 Full Name
Salutation
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Name
First Name
Last Name
Nursery Signature
Signed on behalf of The Little Lane Nursery
Emma Green
Nursery Manager
Date
-
Day
-
Month
Year
Date
All health care plans will be reviewed at least every 6 months, unless anything changes sooner or within the first 6 months following a diagnosis.
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