VOUCHERS FOR:
 
 
 
 
Additional Languages:
 

Please complete the screening information below, then press the “Next” button at the bottom of the page for a printable voucher.
 
Dispense Assist does not retain your protected health information or other personal data that you provide. The only information retained by Dispense Assist is your IP address, which is not directly associated with any of your personal information. You are responsible for the security of any computer you use to input the information. At a minimum, you should clear your browser after you have printed your Voucher.
 
Personal Information
  First Name:        
  Address: 
  Address2/Other: 
City:   State/Territory:  Zip/Postal Code:
  Telephone:  ( ) -
Email: 
  Date of Birth:  / /
  Weight (lbs): 
  Sex:  Male Female
Medical Information
  1. Is this person allergic to Doxycycline, Tetracycline or any other 'cycline' drugs?
Yes No
  2. Is this person allergic to Ciprofloxacin, Levaquin or any other 'floxacin' drug?
Yes No
  3. Does this person have seizure disorder or epilepsy?
Yes No
  4. Is this person currently taking Tizanidine (Zanaflex)?
Yes No
  5. Does this person have difficulty swallowing pills?
Yes No
  6. Does this person have renal (kidney) disease or Myasthenia Gravis?
Yes No
 
 
I have been offered a copy of the Disease Information Sheet. By checking the 'I Agree' box, I consent to receive the antibiotic to be given to me or the person named above for whom I am authorized to sign.
I Agree
 
 After completing the screening information, press the “Next” button for a printable voucher.
 
 

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Funding for this website was made possible (in part) by the Department of Health and Human Services. The views expressed on this website do not necessarily reflect the official policies of the Department of Health and Human Services, nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.