MURRAY CHILDREN’S CENTRE
ASTHMA MEDICATION AUTHORITY FORM
I _______________ (Parent/Guardian) authorise staff at Murray Children’s Centre to
administer the following Asthma medication to my child __________________ (Child).
I understand the potential risks and side effects of this medication for my child.
Child’s name: ____________________________________________
Name of Medication: ______________________________________
Dosage of each administration: _______________________________
What symptoms does your child usually display before a dosage is to be
administered: (please circle) Wheezing, chest tightness, shortness of
breath, all three.
Special instructions: ______________________________________
Expiry Date of Medication: _______________
Has this child been given this or any other medication, including prescribed, pharmacy
bought or alternative or complementary medicine in the previous 24 hours?
Date and Time of last dose: __________________________________________
Other Medication: _________________________________________________
Time of other medication: ____________________________________________
When to seek help from the Doctor/ Hospital
_______________________________________________________
_______________________________________________________
Doctor’s name, address and phone number:
_______________________________________________________
_______________________________________________________
_______________________________________________________
Parent/Guardian Name: _______________________Date: _________
Parent/Guardian Signature: __________________________
Staff Name: ______________________________
Date: ______
Staff Signature: _______________________________
RECORD OF ADMINISTRATION OF MEDICATION
Signature of
Date
Medication
Dose
Time
Given
Given
Person
administering
medication
Signature
of person
checking
medication
Parent
Signature
verifying
that
medication
was given
Medication can only be given to a child if the medication is in its original
packaging. In the case of prescription medication, this can only be
administered to the child for whom it has been prescribed, from a
container bearing a pharmacy label showing the child’s name and a current
use by date, and in accordance with the doctor’s instructions or the
instructions.
For any Asthma medication, the parent or guardian must provide an
Asthma Plan from their doctor which outlines the symptoms of asthma,
medication prescribed, instructions on its administration, side effects to
monitor for, and an emergency or first aid care plan.