DO NOT DISPENSE MEDICATION!
Thank you for submitting your medication form. Unfortunately, your answers indicate that you are unable to receive any of the medications that are currently available. Please contact your health care provider or your local health department for additional information.

Demographic Information
	First Name:	FirstName	Telephone:	Telephone
	Last Name:	LastName	DOB:	DOB
	Address:	Address	Age:	Age
	Address2:	Address2	Sex:	Gendor
	City, St Zip:	CSZ	Weight:	Weight
	Email:	Email

Health History Information
	1. Is this person allergic to Doxycycline, Tetracycline or any other 'cycline' drug?	No
	1a. Has person experienced respiratory (breathing) or cardiac (heart) arrest after taking this medication?	No
	2. Is this person allergic to Ciprofloxacin or any other “floxacin” drug?	No
	2a. Has person experienced respiratory (breathing) or cardiac (heart) arrest after taking this medication?	No
	3. Does this person have seizure disorder or epilepsy?	No
	4. Is this person taking Tizanidine (Zanaflex ©)?	No
	5. Does this person have difficulty swallowing pills?	No
	6. Does this person have renal (kidney) disease or Myasthenia Gravis?	No
	7. Is this person pregnant?	No
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 Notice of Information Practices.

Client Signature:_____________________________________			Date Signed:________________