Antibiotic Information Sheet

Antibiotic Information Sheet

This form will be sent directly to the pharmacy and a prescription will be generated for you. Please wait 24 hours to pick up medication. There is a $40 prescribing fee to be paid now, plus any copay to be paid when medication is received.
Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient DOB*
Patient Weight
Required for Children
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
[email protected]
Medical Conditions
Allergies*
Do you want us to bill insurance?*

YesNo, I will pay out of pocket
Last 4 digits of SSN*
This will be used to get your insurance information.
Copy of Insurance Card, Front and Back*

Cancelof
Travel Destination(s)*
Which Antibiotic Medication would you like to receive?*

CiprofloxacinAzithromycinNo Preference - Pharmacist Pick

Please answer the following questions*

	Yes	No	Unsure
Do you have allergies to any antibiotics?
Are you taking steroids?
Have you had an organ transplant?
Do you have Myasthenia Gravis?
do you have tendon/joint problems? (E.G. ACL Surgery or tendonitis)
Do you have diabetes, heart problems, or are you taking a medication that may affect heart rhythm?
Do you have kidney or liver disease?
Do you have nerve problems/neuropathy?
Are you pregnant or breastfeeding?
Are you taking blood thinners (Warfarin)?
Are you taking anti-virals for HIV?

If yes to any of the above questions, please explain here:
I’ve read the above information and understand the risks of this medication and would like to receive it.
Signature*

Clear

My Products*

Antibiotic Prescribing FeePrescribing Fee

$40.00 Quantity

Total

$0.00

	
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