Medical Kit Questionnaire

First and Last Name

Email address

Phone Number

Pharmacist will call you upon receiving form

Birth Date

Address

For delivery

Kit Options pharmacist will consult with you to personalize kit to your needs

UTI Treatment

$69

Travel Medications -- Anti-diarrheal antibiotics, nausea, etc

$99

Travel+ (High Malaria Risk Travel)

$149

Emergency medications - allergy/anaphylaxis

$299

Emergency medications - diabetic

Price varies depending on need

Emergency medications - opioid rescue

$99

Specific requests/questions for pharmacist

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