Patient Demographics Form
Address LIne 1
Address Line 2
Choose your state
Armed Forces Americas
Armed Forces Europe: Middle East, & Canada
Armed Forces Pacific
District of Columbia
Federated States of Micronesia
Northern Mariana Islands
Prince Edward Island
Medical Health History
Please check any conditions you have:
Immune System Deficency
Please list current medications you take:
Please list any drug allergies:
Do you drink alcohol?
Do you smoke cigarettes?
Please indicate/describe in detail anything else about your health history that you think would be useful or important for your practitioner to know:
By clicking the "Submit Form" button below, I am effectively signing and agreeing to the following statement: "I am only seeking this antibiotic preparedness package in order to be prepared for a situation where conventional medical care is not available. I further agree that if such a "grid-down" situation does not exist, and I have a condition which may require the use of antibiotics, that I will seek evaluation and treatment at my local medical facility and will not use these antibiotics to avoid seeking such an evaluation and treatment"
PLEASE NOTE THAT I AM UNABLE TO SHIP TO A PO BOX. PLEASE PROVIDE A PHYSICAL ADDRESS IN THIS FORM.
PLEASE NOTE, IF YOU RESIDE IN ONE OF THE FOLLOWING STATES, I WILL NOT BE ABLE TO PROVIDE THIS SERVICE TO YOU, AND YOU WILL NOT RECEIVE A REPLY TO SUBMISSION OF THIS FORM:
FL, GA, MA, MO, NJ, NY, OR, PA, WA