St. Michael's School, 198 Hadleigh Road, Leigh-on-Sea, Essex SS9 2LP  Tel: 01702 478719  
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 Online Medicine Record Form
Please complete the form as fully as possible and return it to school useing this online form. If your child does not have any known medical conditions, food allergies, special dietary requirements or medication please put NONE. If any information changes, please notify the school, in writing or refilling in the online form below, so that your child’s records can be amended.
Thank you.


Childs Name:

Class:

Name of Medication:

How much and how often:


Any other instructions? (storage, cautionary advice, details for inhalers)


Contact Phone number:



Details of Family Doctor Name:


Telephone:


I confirm that by submitting this form I give Permission for staff to administer the specified dose of the above medication to the child named on this form.

Agree to above statment:

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