Medication form

Parental agreement for school/setting to administer medicine

Form 3B
The school/setting will not give your child medicine unless you complete and sign this form, and the school or setting has a policy that staff can administer medicine.

Name of school/setting* Date* Child's name* Class* Name and strength of medicine* Expiry date* How much to give (ie dose to be given)* When to be given* Any other instructions Number of tablets/quantity to be given to school/setting*

Note: Medicines must be in the original container as dispensed by the pharmacy

Daytime phone no. of parent or adult contact* Name and phone no. of GP* Agreed review date to be initiated by (name of member of staff)*

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school/setting staff administering medicine in accordance with the school/setting policy. I will inform the school/setting immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped.

Parent's signature Print Name* Date*

If more than one medicine is to be given a separate form should be completed for each one.