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MEDICATION CONSENT FORM

Current Date

Kingsland Nursery will not administer medication unless this medication form is completed in full and signed by a parent / carer

1- Details of child

Surname *

Forename *

Gender *MaleFemale

Date of Birth *

Details of Child’s Condition or Illness *

2- Medication

Name/Type of Medication (as described on the container *

How long will your child be on this medication *

Date Dispensed Prescribed by Doctor / Pharmacist *

3- Full Directions for Use

Prescribed Dosage and Method *

Timing: Frequency of Dosage *

Special Precautions *

Side Effects *

Method of Administration *

Procedures to take in an Emergency *

Storage Requirements *

Expiry Date *

4- Parent/Carer Contact Details

First Name *

Surname *

Relationship with child *

Other *

Daytime Phone No *

I understand and accept this is a service Kingsland Nursery is not obliged to undertake

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