Esta boleta permite al individuo nombrado abajo recibir este medicamento.
TRAIGA ESTA BOLETA CON USTED
 
Dispense Assist
Post Exposure Prophylaxis Voucher
 
Medication:
 
Demographic Information
 First Name: Telephone:
 Last Name: DOB:
 Address: Age:
 Address2: Sex:
 City, St Zip: Weight:
 Email:   
Health History Information
 1. Is this person allergic to Doxycycline, Tetracycline or any other 'cycline' drug?
 1a. Has person experienced respiratory (breathing) or cardiac (heart) arrest after taking this medication?
 2. Is this person allergic to Ciprofloxacin or any other “floxacin” drug?
 1a. Has person experienced respiratory (breathing) or cardiac (heart) arrest after taking this medication?
 3. Does this person have seizure disorder or epilepsy?
 4. Is this person taking Tizanidine (Zanaflex ©)?
 5. Does this person have difficulty swallowing pills?
 6. Does this person have renal (kidney) disease or Myasthenia Gravis?
 7. Is this person pregnant?
 
Yo, el suscrito, certifico que toda la información anterior es correcta de acuerdo a mi conocimiento. Por la presente autorizo al receptor de este documento a compartir esta información con los organismos de salud pública al nivel local, estatal y federal con el fin de garantizar la efectividad y seguridad del medicamento. Se me ha ofrecido una copia del Aviso de Prácticas de Información.
Firma del Cliente:_____________________________________Fecha de Firma:________________
 
Point of Dispensing Use Only:
Medication Provided:  Doxycycline  Ciprofloxacin
 
 Place Lot # Sticker Here
 
Dispensing Site Name:_________________________________
 
Dispenser Signature:____________________ Date:___________
 
Fact sheet: