Medication Form

Hackleton CEVA Primary School

Name of child: *

Email address *

Date of birth: *

Class *

Medical condition/illness: *

Name of medication (as described on the container) *

Dosage, method and timing: *

Start date *

Please enter the date and time that medication should be given from.

End date

Please enter the date and time that medication should stop, if known

Other information *

Please provide any other information that may be required, for example, possible side effects, special dosage details, etc.

Does the medication need to be kept in the fridge? *

Yes

Signature *

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Name