Medication Administration Consent Form

Participant name *

Participant date of birth *

Does the participant have allergies *

Yes No

Provide information on allergies

Provide details on allergic reaction

Provide details on response strategies for allergic reactions

Does the participant have medication that needs to be administered, dosage or managed by support staff? *

YesNo

Please provide names and dosage of medications

Please provide additional information (if applicable)

Do you consent for support staff to administer over the counter medication (eg. Panadol) to the participant? *

YesNo

Please provide details of over the counter medications

Please provide any other information if applicable

I (the below party) agree and give my full consent for staff, who have been assessed as competent in medication support and/or assisting to provide medication to a participant as outlined above.

The Consenting Party agrees to allow the staff worker to carry out the above medication support or assistance at the risk of the Participant as per the pharmacist’s instructions on the medication packaging.

The participant should keep a current list of:

current medicines (prescription, non-prescription medicines, and complementary health careproducts)
any allergies and previous drug reactions
vaccinations.

Such a list can be helpful to ambulance and other emergency workers.

*

Name of consenting party *

Date signed *

Consenting party *

ParticipantRepresentativeAdvocate Other

Signature *

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