Medication Administration Form
For prescribed medication to be administered at nursery
Childs Name
First Name
Last Name
Childs date of birth
-
Month
-
Day
Year
Date
Medication Name, as it appears on the label
Dosage to be administered
Last time medication was given
-
Month
-
Day
Year
Date
Time to administer
Hour Minutes
AM
PM
AM/PM Option
Time to administer if more than once
Hour Minutes
AM
PM
AM/PM Option
Date prescribed by a doctor
-
Month
-
Day
Year
Date
Reason for medication
Additional information
Parent Name
First Name
Last Name
Date that consent given
-
Month
-
Day
Year
Date
Parent Email
example@example.com
Terms and Conditions
Medication must be all medication should be in original named box / bottle and always labelled with the child’s name, DOB, dose and date. (dispensed from the pharmacy). Please supply a measured medicine spoon / syringe. Please give staff all the information required to insure the well-being of the child. At least one dose of the medication has already been administered and my child has not suffered any unwanted reactions. All forms should have clear and specific Reasons, Signs & Symptoms Our day is 24hrs day so 3 times/day means every 8hrs, unless stated by the GP. Staff will log in medication administration on family.
Agreement to terms and conditions
I agree to the terms and conditions above
Submit
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