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Medical Consent Form

 Becket Primary School, Derby

PARENTAL CONSENT FOR ADMINISTRATION OF MEDICINES

BECKET PRIMARY SCHOOL WILL NOT GIVE YOUR CHILD MEDICINE UNLESS YOU COMPLETE AND SIGN THIS FORM.

ALL MEDICINES MUST BE IN THE ORIGINAL CONTAINER AS DISPENSED BY THE PHARMACY AND ANY INSTRUCTIONS WRITTEN IN ENGLISH.

NAME OF CHILD  

 

 DATE OF BIRTH  
 CLASS  
 DOCTOR’S NAME  
 SURGERY PHONE NUMBER  
 NAME & STRENGTH OF MEDICINE  
IS THIS MEDICINE *PRESCRIBED/*NON-PRESCRIBED? (*delete as appropriate)
 DOSE/HOW MUCH?  
 ROUTE e.g. by mouth, in the ear  
 TIMING e.g. lunchtime, after food, when required  
 SIDE EFFECTS?  
ANY KNOWN ALLERGIES?  
*SELF  ADMINISTERED/*REQUIRES SUPERVISION TO ADMINISTER/*REQUIRES ASSISTANCE IN ADMINISTERING MEDICATION (*delete as appropriate)
 EXPIRY DATE  
HOW LONG DOES THIS MEDICINE NEED TO BE GIVEN?  

Parental/Carer signature & up-to-date contact details required.

 I request that the treatment be given in accordance with the above information by a named member of the school staff who has received all necessary training. I understand that it may be necessary for this treatment to be carried out during educational visits and other out of school activities as well as on the school premises.

I accept that whilst my child is in the care of the school, the school staff stand in the position of the parent and that the school staff may therefore need to arrange any medical aid considered necessary in an emergency in line with the school’s Medical Conditions Policy. I will be told of any such action as soon as possible.

I can be contacted at the following address/telephone during school hours:

Name:                                                                                                                                                

Contact Address:                                                                                                                    

                                                                                                                                               

Telephone Number:                                                                                                               

Signed:                                                                       

Date:                                                                          

 

 

THIS FORM WILL BE DESTROYED WHEN THE MEDICATION IS COMPLETED OR CHANGED.

 

 

 

 

 
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