Patient Demographics Form

 

Personal Information

First Name
Last Name
Gender
Age
Phone Number
   
   
Address LIne 1
Address Line 2
City
State
Zip Code
Email Address
   
   
   
   

Medical Health History

   
   
Please check any conditions you have:    
High BP Diabetes
Cancer 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

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