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Online Medicine Record Form



Please complete the form as fully as possible and return it to school using 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:

For the treatment of:


Details on how much to give and how often:


Any other instuctions
Including storage requirements or details for inhalers:


Any Cautionary advice:


Contact Phone number:



Details of Family Doctor Name:


Telephone:






I confirm by submitting the online form that I give written consent for medical staff to administer the specified dose of the above medicine to the child named on this form.
Agree to above statement:

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