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Please complete the screening information below, then press the “Next” button at the bottom of the page for a printable voucher.
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Personal Information
  First Name:        
City:   State/Territory:  Zip/Postal Code:
  Telephone:  ( ) -
  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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