Request for Medicine to be Administered at Gorseland Primary School
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- it is your responsibility to ensure the medicine we hold in school is within date - we are not able to administer out of date medicines.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 *
Required
Other Time (if applicable)
For how long / review date *
MM
/
DD
/
YYYY
Medicine Date of Expiry *
MM
/
DD
/
YYYY
Medical condition / illness *
Any other instructions (side effects, etc)
Submit
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