Request for Medicine to be Administered at Gorseland Primary School

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out the form below to make the school aware of any medicines you need administered during the school day.

These should be prescription medicine only, unless agreed with the school in advance. All medicine must be supplied in the original pharmacy containers showing the prescription label.

In submitting this form you agree to personally deliver the medicine to the school office and to collect it after the end of administering. You will inform the school in writing if there is any change in the dosage, the frequency or if the medication is to be stopped. Please take note of the medicine's expiry date - it is your responsibility to ensure the medicine we hold in school is within date - we are not able to administer out of date medicines.

Parent / Carer's Name *

Relationship to Pupil *

Pupils Name *

Class *

Name of medicine as shown on the container *

Dose *

When *

Before Lunch

After Lunch

As and When required (For Epi-pens and/or Inhalers only)

Required

Other Time (if applicable)

For how long / review date *

YYYY

Medicine Date of Expiry *

YYYY

Medical condition / illness *

Any other instructions (side effects, etc)

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Gorseland Primary. Report Abuse

Forms