DECD Authority Form

This is a request form for an authority for a childcare/kindy/school or OHSC to give medication. It can be used if Dr Lee has already written the prescription in the last year. In this iniital phase of diagnosing and stabilising a child on ADHD medication, this will be written at no charge IF the trial medication forms have been completed and returned (faxed or scanned and emailed) to Dr Lee. If there is a clinical reason that a review is needed, you will be contacted

Child's Name *

First

Last

Parent/Carer's Name *

First

Last

Parent/Carer Mobile Number *

Email *

Medication Name *

Time(s) of day to be given *

Amount of Medication (number of tablets) *

Form (Liquid/Tablet/Puffer etc) *

Any Other Instructions *

For example, "Crushed in jam"" Put nil if no special instructions

Fax Number Of School/Childcare/Kindy *

Cost *

ADHD Trial of Medication (no cost but MUST have returned parent and teacher trial forms)
All Others ($10)

Teacher & School/Kindy/Child Care Name *

Comment

Sunshine Paediatrics

Sunshine is the love of Heaven poured out for all!

DECD Authority Form