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Get Only Complete This Form If Your Child Requires An Epi-pen

Llergy (anaphylaxis) to: Peanut Other: Tree Nuts Insect Stings: Egg Latex Milk Medication: Food: The key to preventing an anaphylactic emergency is absolute avoidance of the allergen. People with food allergies Please attach current should not share food or eat unmarked/ bulk foods or products photo of your child. with a may contain warning. / Epinephrine Auto-Injector: Expiry date Jr. 0.15mg 0.15mg Dosage: Location of auto-injector(s): 0.30mg 0.30mg.

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