This voucher permits the individual named below to receive this medication.
BRING THIS VOUCHER WITH YOU
 
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?
 2a. Has person experienced respiratory (breathing) or cardiac (heart) arrest after taking this medication?
3. Does this person have an allergy to amoxicillin?
 4. Does this person have seizure disorder or epilepsy?
 5. Is this person taking Tizanidine (Zanaflex ©)?
 6. Does this person have difficulty swallowing pills?
 7. Does this person have renal (kidney) disease or Myasthenia Gravis?
 8. Is this person immunocompromised (AIDS)?
 9. Has this person experienced an adverse reaction to AVA vaccine?
 10. Is this person pregnant?
 
I, the undersigned, certify that all of the above information is correct to the best of my knowledge. I hereby authorize the recipient of this document to share this information with public health entities at the local, state and federal level for purposes of ensuring medication efficacy and safety. I have been offered a copy of the Vaccine Information Statement(s)(VIS) for AVA. I have read, had explained to me, and understand the information on the VIS(s). I ask that the vaccine(s) be given to me or to the person named for whom I am authorized to make this request
Client Signature:_____________________________________Date Signed:________________
 
Point of Dispensing Use Only:
Medication Provided:  Doxycycline    Ciprofloxacin    AVA
 
 Lot # C/D Sticker  Lot # AVA Sticker 
 
Dispensing Site Name:______________________________________
 
Dispenser Signature:___________________________    Date:_____________
 
Fact sheet: