Client Medication Plan & Consent Form

This form is designed to provide a snapshot of medications clients require us to Prompt, Assist or administer Medications. This form has been completed by the Caring Lotus team for you to review and sign if you agree to it.

If you have any questions, please either call us on (03) 7036-1516 or email us at care@caringlotus.com.au.

Client Name*

Date of birth

Date

Address

Consenting Party

Name of person consenting

Email for Client Correspondence

example@example.com

Medication

	Schedule 8	Prompt Remind or Administer	Open Packet	Give Medication	Apply	Store Medication
Ear Drops
Eye Drops
Liquid Medication
Medical Cream
Nitrolinqual Pumpspray
Inhaler
Tablets in Blister Pack
Transdermal Patch

Specific details

The Consenting Party agrees to allow the staff to carry out this Medication Plan at the risk of the Client listed as per the pharmacist's instructions on the medication packaging.

Participant/Client/Carer/Advocate encourages you to keep a current list of:

All of your current medicines (prescription, non-prescription medicines, and complementary health care products);
Any allergies and previous drug reactions; and
Vaccinations.

This list can be very helpful to an ambulance and other emergency workers.

Client Agreeement by

verbally by phoneby physical hard copyElectronic SignatureOther

Client/Consenting party signature

Date Client/Representative signed

Date

Employee signature

Employee Name

Date Employee signed

Date

Please upload any supporting documents

Browse Files

Medication list by Doctor or pharmacist, allergies, details etc.

Send to client?

YesNo

Caring Lotus

CLIENT MEDICATION PLAN & CONSENT FORM

Medication Plan and Consent agreement