Medicine Administering Form

Name of child:* Date of birth:* Form Group:* Medical condition or illness:*

Medicine

Name/type of medicine: (as described on the container)* Expiry date:* Dosage and method:* Timing:* Special precautions/other instructions:* Are there any side effects that the school/setting needs to know about?*

Self-administration:*YesNo

Procedures to take in an emergency:*

NB: Medicines must be in the original container as dispensed by the pharmacy.

Contact Details

Name:* Daytime telephone number:* Relationship to child:* Address:*

The information above is, to the best of my knowledge, accurate at the time of writing and I give consent to school/setting staff administering medicine in accordance with the school policy.
I also consent to the school contacting the School Nurse Team if necessary.
I will inform the school/setting immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped.

Sutton Coldfield
Grammar School for Girls

Medicine Administering Form

Medicine

Contact Details

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