Medicine Consent Form - Preparatory School Croydon

Consent Form to Administer Medicines:

The school staff will not give any medication unless this form is completed and signed. I request and authorise that my child *be given/gives himself/herself the following medication: (*delete as appropriate)
Name of Child:*
Date of Birth*
DD slash MM slash YYYY
Class/Form Group*
Name of Medicine:*
Expiry Date of the Medicine*
Special precautions e.g. take after eating etc*
Has your child previously taken this medication?*
Are there any side effects that the school needs to know about?*
Time of Dose*
Dose Amount*
Start Date*
Finish Date*
Name of medical Professional (GP)*

This medication has been prescribed for my child by the GP/other appropriate medical professional whom you may contact for verification.
GP Contact telephone number:*
Consent*
I confirm that:
Yes, It is necessary to give this medication during the school/setting day
Yes, I agree to collect it at the end of the day/week/half term (delete as appropriate)
Yes, This medicine has been given without adverse effect in the past.
Yes, The medication is in the original container indicating the contents, dosage and child’s full name and is within its expiry date.
Email Address for Copy of this Form:*

Enter your email address and we will send you the copy of this form for your record.
Signature*

Medicine Consent Form – Preparatory School Croydon