Medicine Administration Consent Form

Participant Name

Nominee (Guardian) Name

Email Address

I confirm that I require medicine to be taken in accordance with medical advice. I give consent to BOORN to administer my medicine as per the instructions on the medication label and contact the prescriber or pharmacy if there are any administration concerns.

Provide medication support which may involve reminding or prompting me to take my medicine or assisting me to open medicine containers.

Provide medication assistance which may involve storing medicine, opening medicine containers, removing the prescribed dose from the medication containers, and administering the medicine as per instructions.

Which of the following actions you would like BOORN to carry out.

Provide medication support Provide medication assistance

Declaration by BOORN:

A suitably qualified team member will provide support or assistance with medication when given consent by the participant
BOORN team members will record all instances of medicine administration on the participant’s chart
BOORN team members will ensure that the storage of medicines where they are responsible is appropriate for each medicine and all medicines are kept safely and securely

I understand that I am required to complete a Medication Schedule and Adminstration Chart in person with the assistance of a Boorn Team Member for every Medication required. *

Signature

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Date