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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.
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:	Last Name:
	Address:
	Address2/Other:
	City:	State/Territory: --Select One-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming  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
	1a.	Has this person experienced respiratory (breathing) or cardiac (heart) arrest after taking this medication?	Yes No
	2.	Is this person allergic to Ciprofloxacin, Levaquin or any other 'floxacin' drug?	Yes No
	2a.	Has this person experienced respiratory (breathing) or cardiac (heart) arrest after taking this medication?	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
	7.	Is this person Pregnant?	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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