Short Term Medication Form

Child's Name:(*)

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Reason for Medication:(*)

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Special instructions/possible side effects(*)

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Start Date:(*)

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End Date:(*)

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All medications must be in the original pharmaceutical containers/packaging & within its use by date so the centre can be certain of the medication and dosages prescribed by the doctor.

Date:(*)

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Name of Child:(*)

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Date and Time of last dosage(*)

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Name of Medication:(*)

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Self Administered?(*)

YesNo

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Expiry Date:(*)

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Method:(*)

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Dosage:(*)

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Time to be given:(*)

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TO BE COMPLETED BY PARENT/CAREGIVER

I request that my child(*)

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be administered the above mentioned medication as per instructions provided.

A copy of the dosage as prescribed by the medical practitioner is attached above.

Print Name:(*)

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Email Address:(*)

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Dated:(*)

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Parent/Guardian signature:(*)

Sign Above

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