Upgrade your First Aid Kit

Upgrade your First Aid Kit

Please fill out form with necessary information as needed. Be advised that all the information submitted is completely confidential.
This form will record your name, please fill your name.*
Name*

First Name Last Name
Date of Birth*

MonthDay Year
Date
Sex*

FemaleMale
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Upload an image of the front of your driver's license.

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Do you have health insurance?*

YesNo
Primary Prescription Insurance Name
Primary Insurance BIN
Primary Insurance PCN
Primary Insurance member ID
Primary Insurance Group Number
Upload an image of your insurance card front.

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Upload an image of your insurance card back.

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Please select all that apply. Be advised that all the information submitted is completely confidential.*

Voluntary RequestRecipient of emergency care for acute opioid poisoningIllicit or non-medical opioid userHigh dose opioid prescription (> 100 morphine equivalent per day)Any methadone prescription to opioid naïve patientAny opioid prescription and smoking/ COPD or other respiratory illness or obstructionAny opioid prescription for patients with renal dysfunction or hepatic diseaseAny opioid prescription and known/suspected concurrent alcohol useAny opioid prescription and concurrent benzodiazepine prescriptionsAny opioid prescription and concurrent SSRI or TCA anti-depressant prescription.Patients recently released from a correctional facilityPatients recently released from an opioid detoxification and mandatory abstinence programPatients entering methadone maintenance treatment programs (for addition or pain)
17. Note to Pharmacy Staff
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