Managing Medications Form printable pdf download

Managing Medications Form

Note:

Please read the guidance overleaf before completing this form.

SIF 11a/10

It is the responsibility of parents/guardians to give full and accurate information on their child’s medical condition and medication

requirements. If unsure, parents/guardians should seek advice from their child’s General Practitioner or Medical Consultant.

PART A: Child’s Information

Childs Name:

_____________________________________

Date of Birth:_______________________

Childs Address: _______________________________________________________________________________

PART B: Medication Information

Name of Medicine : ____________________________________________________________________________

Dosage to be taken: ___________________________________________________________________________

Frequency of Dosage: ______________________

Quantity Supplied:___________________

Prescribing Doctor (name): ____________________________________ Telephone Number __________________

Dispensing Pharmacy (name): _________________________________ Telephone Number__________________

Method of Administration (e.g. to be taken before, with, or after food): ____________________________________

Other relevant Information: (e.g. does medication cause drowsiness, headaches, rash or other

contra-indications) :

____________________________________________________________________________________________

Can your Child Self–Administer their medication (tick appropriate box)

YES

PART C:

Parent /Guardian Declaration

I confirm that I have read the guidance notes overleaf and that I have given full and accurate information on my child’s

medication on this form. I hereby request and authorise the Scouters named below to administer the medication outlined

above to my child from ________________ (insert date) until ________________ (insert date). I understand that if my

child refuses to take their medication that I will be contacted and informed.

Scouter 1: _________________________________

Scouter 2: _________________________________

Signature of Parent / Guardian:______________________ Date:___________________

Managing Medications Form