Medicine consent form and dose record
One form for each medicine, filled in and signed by the child's parent or carer before the first dose.
| Child's full name | | Date of birth | |
| Medicine and strength | | Dose (as on the label) | |
| Prescribed? | No Yes, by: doctor / dentist / nurse / pharmacist In its original labelled container |
| What it is for | | How it is given | |
| When (set times, or as needed and how far apart) | |
| From and until (dates) | | Last dose at home | |
| Side effects or allergies | |
Parent or carer
| I give permission for this medicine to be given as above. Signature | |
| Name | | Date | |
Each dose
| Date | Time | Dose given | Given by | Checked by | Notes (refused, reaction) | Parent told (when, by whom) |
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◆ Required by the EYFS, paragraphs 3.61–3.62 (childminders 3.60–3.61). Everything else is good practice.