Medication Consent Form

Please complete the form below. We'll review the medication details and be in touch if needed.

My child has been prescribed the medication(s) listed below and I agree to Primary Playcare staff administering this/these at agreed times.

Personal details

Name of child Date of birth

Address

Parent/Carer name Telephone number

Relationship to child Email (optional)

Medication details

Name of medication Expiry date

Dose Times

Why is this medication required?

Important: Staff will not administer the first dose of any medication a child has never been previously prescribed. The child should have received at least one dose prior to staff administering to ensure there are no adverse reactions.

I confirm my child has previously received at least one dose of this medication.

Dose is “as and when required”

Parent/Carer consent I give consent for Primary Playcare staff (in accordance with their Administration of Medication Procedure) to administer this medication as detailed above. I will deliver the medicine personally to a member of Primary Playcare staff and understand I will be kept fully informed of any medications administered.

For office use

I have received the medication detailed on this form and checked it matches the prescription label.

Staff member Date

Parent/Carer (name) Date

Please wait while your form is processed.

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