Buccal Midazolam 10 mg in 1 mL (multidose bottle preparation) First Dose Authorisation Form



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Buccal Midazolam 10 mg in 1 mL (multidose bottle preparation)

First Dose Authorisation Form


I, the prescriber:…………………………………………………………………………………………….....…(child’s clinician)

……………………………………………………………………………….……………………………………………(base & contact tel. no)

give permission for the buccal administration of Midazolam preparation dispensed as 10mg in 1mL

multidose bottle by staff who have attended specific training. I take full responsibility for this medication to be given as outlined below.

SIGNED:…………………………………………………..…………………. DATED: …………………………..………………...................




NAME OF CHILD: ...…………………………………………………………..………………… DOB: …………………………………………………...

NHS No: …………………….……………School:………………………………………………………….…………………………………………………..

Home Address: ………………………………………………………………………………….…………………………………………………………………

Other Setting: ……………………………………………………………………………………..……………………………………………………………..

PRESCRIBED DOSE: ……………..…..… mg




mL


Amount to be administered in mL:

ROUTE: BUCCAL

To be given if seizure lasts longer than: ……….…minutes

Special instructions (if required): ………………………………………………………………………………………………………………….…...

……………………………………………………………………………………………………………………………………………………………………………


When to call for a Paramedic Ambulance:

  • Whenever any emergency rescue medication is being given to this child for the first time in a

school/setting.

  • If the seizure has not resolved after ………minutes following administration of Buccal Midazolam.



  • Other ……………………………………………………………………………………………..………………………………………….




Instructions for administration

Take the multidose bottle and the 1 mL oral dispenser supplied with this medication. Draw up the

liquid as instructed using the oral dispenser until the black mark on the plunger reaches the correct

mL’ mark. Place the tip of the dispenser into the buccal area of the child’s mouth, between the

cheek and the gum of the lower jaw, by the back teeth. Then slowly empty the contents of the

dispenser. Remove dispenser from the child’s mouth and gently hold lips together for a few



seconds to allow absorption.


The authorisation form must be updated annually or whenever there are any changes to the child’s emergency rescue medication details.



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