Get Medicine (A)

Screening Form

Answer the questions below for yourself and for each person for whom you are picking up medicine.  After answering all questions, click the Add Another Recipient button each time you want to add another person.  When you have answered questions for all of the people for whom you will be picking up medicine, click on the Complete Process and Print button.  You can answer questions for up to twenty (20) people at a time.

1. Please enter the first name of the person in need of medicine
2. Please enter the last name of the person in need of medicine.
3. Is this person allergic to Doxycycline,Tetracycline or any other "cycline" drug?
4. Is this person pregnant?
5. Is this person under 9 years old?
6. Is this person BOTH under 18 years old AND weigh less than seventy-six pounds (76 lbs)?
7. Is this person allergic to Ciprofloxacin or any other "floxacin" drug?
8. Is this person currently taking Tizanidine (Zanaflex©)?
9. Does this person have Myasthenia Gravis?
10. Is this person BOTH under 18 years old AND weigh less than sixty-seven pounds (67 lbs)?
11. Is this person physically unable to swallow pills even if the person's life depended on it?
12. Please enter a ZIP code or select the county where you wish to pick up the medicine.
Zip 
PLEASE NOTE - Your personal information will NOT be saved and will only appear on your printed results. Please regard your printed screening form results as you would your other personal medical records.