Record of Medicine Administered
Please read the statement below and supply us with any required information.

You must complete all required sections to submit this form. YOU CAN NOT SAVE AND RETURN.
Email address *
Child Name *
Date of birth *
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DD
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Medical condition *
Name of medicine *
Name of person administering medicine *
Date medicine administered
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DD
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Brief description of why your child takes this medicine, including how often and instructions showing the dosage. The more information you can give us the better equipped we will be to take care of your child. *
Name GP / Doctor
Telephone number of GP / Doctor *
I understand that all medicines should be clearly labelled with the child’s name and the name of the medicine and given directly to Kiki or Mark. It is vital that we have the name of the medicine in case of an emergency. *
If yes, you must provide confirmation/proof from your doctor.
Signature *
Date of signature *
MM
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DD
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YYYY
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