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Anaphylaxis Plan

Client Details

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Child Details

First Name*
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Last Name*
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Anaphylaxis Plan

An Anaphylaxis Plan must be in place for every child who suffers from Anaphylaxis. Anaphylaxis is a severe, life-threatening allergic reaction. Please complete the below action plan for the relevant child below. If you have a specific action plan created by your doctor, please ensure you upload a copy with this form, so we can provide a copy your Educator.
Confirmed Allergens*
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Symptoms/what to look out for*
For example, swelling of lips, face, or eyes and a tingling mouth.
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List of child's usual medicines (EpiPen or Anapen)*
Please include name of medicines, doses, when to take each dose.
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Instructions on what the Educator should do if there are signs of a moderate allergic reaction*
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Signs of a severe allergic reaction and what to do if the Educator sees these signs*
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What to do in an anaphylaxis emergency (if she child does not respond to initial treatment)*
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Please upload any supporting evidence or documentation here*
5MB max file size. Allowed file types: jpg, jpeg, png, gif, pdf, docx
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By submitting this form you confirm that the above plan accurately reflects that of the child’s treating practitioners and that you will update as per policy guidelines.