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Consent form for the administration of prescription/ non prescribed drugs
Please complete the form and submit along with proof of prescription.
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Email *
Child's Name *
Child's DOB *
MM
/
DD
/
YYYY
Parent's Name *
Relationship *
Daytime Telephone Number *
Procedures to be taken in an emergency
Name of Doctor *
Surgery Address *
Surgery Telephone Number *
List of Medication, Dosage and Frequency
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