Gretton School | Medication Consent Form
Pupil Details

Name of Pupil

ADNO

Date of Birth

Form Group

Medicine Details

GENERIC Name of Medicine

I.e. the name of the medicine itself, not the brand name

BRAND Name of Medicine

If not applicable, please leave blank

Is this a Prescribed Medicine?

Expiry Date

Medicine strength

For oral suspensions, please specify strength as mg/mL - this will be printed on the medicine bottle.

Form

Dosage and method

This information can be found on the printed pharmacy label. DOSAGE refers to the number of tablets, volume of liquid, or number of spray-pumps. STRENGTH is recorded elsewhere in this form.

PRN vs Timed Medicine

Some medicines need only be taken when the student needs them, they are referred to as 'PRN' medicines, from the Latin pro re nata meaning "for the onset [of the symptoms]" - for example, inhalers and epi-pens are only used when they are needed, not on a regular schedule.

All other medicines are administered on a regular schedule, and are considered to be 'timed' medicines. Please select the relevant option below.

Administration Times

Four 'meds administrations' occur throughout the school day. Please select the administration slot(s) at which the student's medication should be administered. If a different time is required, please specify.

Side Effects

Please specify any side effects the school should be aware of. If none, please enter 'None'

Special precautions or other instructions

Emergency procedures

In the event of an emergency, is there any information that medical staff should be aware of. If none, please enter 'None'

Note on Self-Administration

"Self-administration," in this context, generally refers to the process of handling and using equipment such as metered-dose inhalers, spacers, or auto-injectors independently. Our medically trained staff can support young people to correctly use this equipment, if necessary.

All orally administered medicines (tablets, capsules, oral suspensions) are generally stored securely by medical staff, and dispensed at the appropriate times for the young person to take under supervision. Again, our medically trained staff can support young people to ingest their medication, if necessary.

At Gretton, students autonomy and consent is placed at the core of what we do. All students hold the right to refuse medical treatment, and as such, cannot be compelled to take any medicines, even if they are prescribed.

Is this medicine self-administered by the student?

PRN Medicine Protocol

Dosage Criteria

How often can dose be repeated

Max in 24 hours

How the decision is reached about how and when to give

Actions to take prior to administration

Actions to take post-administration

Expected Outcomes

Follow Up

N.B. Parents / Carers will be informed as a matter of protocol, if a student has made use of their PRN medication during the school day.

Circumstances for Reporting to the GP (tick as appropriate)

Contact Details

Contact Name

Relationship to pupil

Contact Telephone

Contact Address

Declaration

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school staff administering medicine in accordance with the school policy. I will inform the school immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped

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NB: Medicines must be in the original container as dispensed by the pharmacy. 

They must also be supplied with a completed Medications Receiving Form which can be found attached to this webform.

Office Only

Review Date

Medical Co-ordinator's Notes (hidden)