In accordance with relevant WHS standards, policies and legislations, this form must be completed prior to the administration of any prescription or non-prescription medication.

PRESCRIPTION MEDICATION will be administered in accordance with the printed prescription label, which must be attached to the original prescription container

NON-PRESCRIPTION MEDICATION must be in original container, and will be administered in accordance with the manufacturer’s printed instructions. If there are no manufacturer’s printed instructions for the age of the child, the program may administer the non-prescription medication in accordance with the written, dated and signed instructions from the child’s parent, including a statement that the instructions have been reviewed/approved by the child’s licensed health practitioner, or with signed, dated written instructions from child’s licensed health practitioner.


I authorise childcare personnel at Sparkling Stars Childcare Centre to administer the following medication to my child: _Sophie Lancaster, 6 y/o____________ _____22 October _____

Name of medication Dosage Times to administer Beginning date Ending date
Children’s Allegra Allergy 1 teaspoonful every 12 hours As needed 7 June 2014 7 June 2015
Advair Diskus 100/50 1 inhalation, 2x daily 9am (9pm is given at home) 7 June 2014 7 June 2015
Child’s Health Practitioner Information
Complete Name: Curtis Langley
Contact Number/s: 0414 451 238
Address: Oakwood Kinsgston Highway, EAST BRISBANE, 4169, QLD, AUSTRALIA
Special instructions for administration of non-prescription medication
(Children’s Allegra Allergy) Shake well before dispensing medicine from bottle (Advair) give through orally inhaled route only. After inhalation, the child should rinse his/her mouth with water after use. Do not swallow rinse water.
The above special instructions were: Reviewed and approved by the above named licensed health practitioner Completed by the licensed health practitioner who’s signature appears below
Licensed Health Practitioner’s Signature Date Signed
C. Langley 7 June 2014

(to be completed by child care personnel for all medication administered)

Name of Medication Amount Time Date Initials
Name of Medication Amount Time Date Initials

_________________________________________________________ _________________
Signature and title of person supervising administration of medication Date signed

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