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Décharge administration de médicaments non prescrits

CONSENT TO ADMINISTER
NON-PRESCRIBED MEDICATION
DECHARGE POUR
L’ADMINISTRATION DE
MEDICAMENTS NON-PRESCRITS
I authorize that my child / J’autorise mon enfant

Full Name of Student / Nom, prénom: ____________________________________________________________________
Date of Birth / Date de naissance________________________________________________________________________
Gender / sexe: Male / masculin Female / féminin
Nationality / nationalité: ______________________________________________________________________________
Address / adresse: ___________________________________________________________________________________
Phone No / n° de téléphone _______________________________ Grade / Classe : _________________________ Be given the appropriate non-prescribed medication in the following cases: à recevoir le traitement approprié mais non préalablement prescrit par votre médecin dans les cas suivants : 1. Administration of Epinephrine in an acute allergic reaction (anaphylactic shock) Administration d’épinéphrine en cas de réaction allergique grave (choc anaphylactique) 2. Administration of Salbutamol Inhaler to control asthmatic symptom Administration de salbutamol par inhalateur en cas d’asthme 3. Administration of oral glucose for hypoglycemia (low blood sugar) Administration de glucose par voie orale en cas d’hypoglycémie 4. Administration of Paracetamol to control mild to moderate pain and fever Administration de paracétamol en cas de douleur ou de fièvre faible à modérée Autre, merci de préciser _______________________________________________________________________ Any precautions the school personnel should know? Any contra-indications that the school personnel should know? Précautions particulières à prendre par le personnel de Contre-indications que le personnel de l’école doit connaître : l’école : What are possible reactions/side effects? What should be done in the event of reaction/side effect? L’enfant est-il sujet à des effets secondaires ? Que doit-il être fait en cas d’effet secondaire ? CONSENT TO ADMINISTER
NON-PRESCRIBED MEDICATION
DECHARGE POUR
L’ADMINISTRATION DE
MEDICAMENTS NON-PRESCRITS
Check appropriate boxes below / cochez la case appropriée 1. I authorize designated school personnel to administer the above medications J’autorise les personnels du lycée habilités, à administrer les médicaments ci-dessus 2. The above medication can only be administered by a HAAD Registered School Nurse. Les médicaments peuvent être administrés exclusivement par une infirmière accréditée par la Health Authority of Abu Dhabi I agree to hold the school and its employees harmless from any and all liability for the results of taking the medication or the manner in which the medication is given. L’administration de médicaments et ses éventuels effets ne pourront engager la responsabilité de l’école et de ses employés. I give my consent for school authorities to take appropriate action for the safety and welfare of my child. J’autorise l’école à prendre toutes les mesures appropriées pour la sécurité et le bien-être de mon enfant. Full name of Parent/Guardian: Nom, prénom du responsable légal ____________________________________________ Signature: _________________________________ Date : __________________________

Source: http://www.llm.ae/administration/Infirmerie/Decharge.pdf

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