Tadworth Primary School
Pupil Medication Request
Child’s Name ______________________________________________
Parent’s Name _____________________________________________
Condition or illness _________________________________________
Parent’s Contact No _________________________________________
GP Name ____________________________ Tel No _______________
Please tick the box below
With supervision my child will be responsible for the self-administration of medicines as
directed below.
I will ensure that the medicine held by the school has not exceeded its expiry date.
Name of medicine
Dose
Frequency/Time
Completion date
of course
Expiry date of
medicine
Special instructions
Allergies:
Other prescribed medicines child takes at home
PLEASE NOTE WHERE POSSIBLE THE NEED FOR MEDICINES TO BE
ADMINISTERED AT SCHOOL SHOULD BE AVOIDED. PARENTS ARE
THEREFORE REQUESTED TO TRY AND ARANGE THE TIMING OF DOSES
ACCORDINGLY
Signed ___________________________________ Parent/Guardian
Print Name _______________________________ Date ____________
Medicine received by ______________________ School representative
Print Name ______________________________ Date ______________