Long Term Prescription Medicines Form

Long Term Prescription Medicines

If your child requires medication on a regular basis during the school day and you have already discussed this with Helen Lawton and/or you need to make a change to an existing prescription please use this form.

Parental Agreement for School to Administer Prescribed Medicine 

The school will not give your child medicine unless you complete and sign this form, and the school has a policy that the staff can administer medicine.

If more than one medicine is needed then a separate form must be completed for each one.Please add any additional information on the reverse of the form.

Name of school
Bishops Down Primary School
Name of child
 
Date of birth
 
Year/Class
 
Medical condition or illness
 

 

Medicine medicines must be in the original container as dispensed by the pharmacy
Name and strength of medicine (as described on container)
 
Date dispensed
 
Expiry date
 
Number of tables/quantity given to the school
 
Agreed review date to be initiated by Helen Lawton
 
Dosage (eg ml/mg) and method (eg by mouth, topical, inhaled)
 
Time/s to be given
 
Special Precautions
 
Potential Side effects
 
Self Administration (Yes or No: please write in the box to the right)
 
Procedure to take in an emergency
 

 

Contact Details
Name and daytime phone no. of parent/adult contact
 
Relationship to child
 
Name and phone number of GP
 

 

  • The above information is, to the best of my knowledge, accurate at the time of writing and I give my consent to the school administering the medicine in accordance with the medicines policy. I will inform the school in writing is there is any change in dosage or frequency of the medicine or if it is stopped.
  • I understand that I must deliver the medicine personally to the school office or school nurse.
  • I accept that this is a service that the school is not obliged to undertake.
 
 
Date………………… Signature………………………………………..Print Name...............................