Antibiotic Prep Program

Antibiotic Prep Program

Medicine fulfillment provided under and by foreign medical practitioners
General Information
Full Name*

First NameLast Name
Birth Date

MonthDayYear
Shipping Address*

Street Address or Box Number

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number

Country CodeArea CodePhone Number
Gender
Medical History
Are you under the care of a qualified healthcare professional? Please list whom.*
I acknowledge that I will remain under the care of a local healthcare professional who will continue to monitor any medications I take and any health concerns that i have.*

I acknowledge
What medications, supplements and over the counter items do you take regularly or are currently prescribed:*
Any past surgeries and hospitalizations?*
Please list any/all allergies

Health History*

	No, never	Yes, currently	Not currently, but within the last year	Not currently and longer than 1 year ago
Fatigue
Depressive symptoms
Anxiety
Thyroid problems
Diabetes
Blood sugar irregularities
Headache
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Constipation
Diarrhea
Liver problems
Kidney problems
Irregular Heartbeat
Are you pregnant/breastfeeding
Epilepsy / Seizures
Cancer

Any additional Health History information or explanation you would like to provide?
Medicine Requested
Medicine (s) requested - check all that apply*

Albendazole (Albenza)Amoxicillin (Amoxil/Trimox)Amox/Clav (Augmentin)Azithromycin (Zithromax/Z-Pack)Cephalexin (Keflex)Ciprofloxacin (Cipro)Clindamycin (Dalacin)Doxycycline (Vibramycin)Fenbendazole (FenBen)Fluconazole (Diflucan)Hydroxychloroquine (Plaquenil)Ivermectin (Stromectol) - MAY SALEMebendazole (Vermox)Metronidazole (Flagyl)Nitazoxanide (Alinia)Nitrofurantoin (Macrobid)Sulfamethoxazole/Trimethoprim (Bactrim DS)Other
Quantity of Albendazole sent through Insulinhub.com portal. Amoxicillin*

Albendazole 400mg chewable tablets (by GlaxoSmithKline) x 100 @ $150Albendazole 400mg chewable tablets (by GlaxoSmithKline) x 200 @ $275Albendazole 400mg chewable tablets (by GlaxoSmithKline) x 300 @ $399Albendazole 400mg chewable tablets (by GlaxoSmithKline) x 400 @ $499nothing at this time
Quantity of Amoxicillin 250mg sent through Insulinhub.com portal.*

Amoxicillin 250mg capsules x 150 capsules (by Abbott) @ $39Amoxicillin 250mg capsules x 300 capsules (by Abbott) @ $69Amoxicillin 250mg capsules x 450 capsules (by Abbott) @ $99nothing at this time
Quantity of Amoxicillin 500mg sent through Insulinhub.com portal.*

Amoxicillin 5000mg capsules x 150 capsules (by Abbott) @ $49Amoxicillin 500mg capsules x 300 capsules (by Abbott) @ $89Amoxicillin 500mg capsules x 450 capsules (by Abbott) @ $125nothing at this time
Quantities of Augmentin (Amox/Clav) requested to be sent through InsulinHub.com portal*

Amox/Clav 250/125mg x 30 tablets @ $25Amox/Clav 250/125mg x 60 tablets @ $45Amox/Clav 250/125mg x 90 tablets @ $65Amox/Clav 250/125mg x 180 tablets @ $125Augmentin 250/125mg (BRAND by GlaxoSmithKline) x 30 tablets @ $49Augmentin 250/125mg (BRAND by GlaxoSmithKline) x 60 tablets @ $75Augmentin 250/125mg (BRAND by GlaxoSmithKline) x 90 tablets @ $99Augmentin 250/125mg (BRAND by GlaxoSmithKline) x 180 tablets @ $175nothing at this time
Quantities of Augmentin (Amox/Clav) requested to be sent through InsulinHub.com portal*

Amox/Clav 500/125mg x 30 tablets @ $25Amox/Clav 500/125mg x 60 tablets @ $45Amox/Clav 500/125mg x 90 tablets @ $65Amox/Clav 500/125mg x 180 tablets @ $125Augmentin 500/125mg (BRAND by GlaxoSmithKline) x 30 tablets @ $49Augmentin 500/125mg (BRAND by GlaxoSmithKline) x 60 tablets @ $75Augmentin 500/125mg (BRAND by GlaxoSmithKline) x 90 tablets @ $99Augmentin 500/125mg (BRAND by GlaxoSmithKline) x 180 tablets @ $175nothing at this time
Quantities of Augmentin (Amox/Clav) requested to be sent through InsulinHub.com portal*

Amox/Clav 875/125mg x 30 tablets @ $35Amox/Clav 875/125mg x 60 tablets @ $65Amox/Clav 875/125mg x 90 tablets @ $95Amox/Clav 875/125mg x 180 tablets @ $175Augmentin 875/125mg (BRAND by GlaxoSmithKline) x 30 tablets @ $59Augmentin 875/125mg (BRAND by GlaxoSmithKline) x 60 tablets @ $99Augmentin 875/125mg (BRAND by GlaxoSmithKline) x 90 tablets @ $125Augmentin 875/125mg (BRAND by GlaxoSmithKline) x 180 tablets @ $199nothing at this time
Quantity of Azithromycin requested to be sent through InsulinHub.com portal*

Azithromycin 250mg x 60 tablets (eq to 10 Z-packs) @ $75Azithromycin 250mg x 120 tablets generic (eq to 20 Z-packs) @ $135Azithromycin 250mg x 180 generic (eq to 30 Z-packs) @ $195nothing at this time
Quantity of Cephalexin 250mg requested to be sent through InsulinHub.com portal*

Cephalexin 250mg x 100 capsules (by GlaxoSmithKline) @ $45Cephalexin 250mg x 200 capsules (by GlaxoSmithKline) @ $85Cephalexin 250mg x 300 capsules (by GlaxoSmithKline) @ $125Keflex 250mg (BRAND by Eli Lilly) x 100 capsules @ $75Keflex 250mg (BRAND by Eli Lilly) x 200 capsules @ $125Keflex 250mg (BRAND by Eli Lilly) x 300 capsules @ $175nothing at this time
Quantity of Cephalexin 500mg requested to be sent through InsulinHub.com portal*

Cephalexin 500mg x 100 capsules (by GlaxoSmithKline) @ $55Cephalexin 500mg x 200 capsules (by GlaxoSmithKline) @ $95Cephalexin 500mg x 300 capsules (by GlaxoSmithKline) @ $135Keflex 500mg (BRAND by Eli Lilly) x 100 capsules @ $75Keflex 500mg (BRAND by Eli Lilly) x 200 capsules @ $125Keflex 500mg (BRAND by Eli Lilly) x 300 capsules @ $175nothing at this time
Quantity of Ciprofloxacin 250mg requested to be sent through InsulinHub.com portal*

Ciprofloxacin 250mg x 100 tablets @ $39Ciprofloxacin 250mg x 200 tablets @ $69Ciprofloxacin 250mg x 300 tablets @ $99BayCip 250mg (BRAND by Bayer) x 100 tablets @ $75BayCip 250mg (BRAND by Bayer) x 200 tablets @ $125BayCip 250mg (BRAND by Bayer) x 300 tablets @ $175nothing at this time
Quantity of Ciprofloxacin 500mg requested to be sent through InsulinHub.com portal*

Ciprofloxacin 500mg x 100 tablets @ $49Ciprofloxacin 500mg x 200 tablets @ $89Ciprofloxacin 500mg x 300 tablets @ $125BayCip 500mg (BRAND by Bayer) x 100 tablets @ $75BayCip 500mg (BRAND by Bayer) x 200 tablets @ $125BayCip 500mg (BRAND by Bayer) x 300 tablets @ $175nothing at this time
Quantity of Clindamycin 150mg requested to be sent through InsulinHub.com portal*

Dalacin 150mg (BRAND by Pfizer France) x 60 capsules @ $49Dalacin 150mg (BRAND by Pfizer France) x 120 capsules @ $89Dalacin 150mg (BRAND by Pfizer France) x 180 capsules @ $125Dalacin 150mg (BRAND by Pfizer France) x 240 capsules @ $155nothing at this time
Quantity of Clindamycin 300mg requested to be sent through InsulinHub.com portal*

Dalacin 300mg (BRAND by Pfizer France) x 60 capsules @ $49Dalacin 300mg (BRAND by Pfizer France) x 120 capsules @ $89Dalacin 300mg (BRAND by Pfizer France) x 180 capsules @ $125Dalacin 300mg (BRAND by Pfizer France) x 240 capsules @ $155nothing at this time
Quantity of Doxycycline 100mg requested to be sent through InsulinHub.com portal*

Doxycycline 100mg x 100 capsules @ $49Doxycycline 100mg x 200 capsules @ $89Doxycycline 100mg x 300 capsules @ $125Doxycycline 100mg x 400 capsules @ $155nothing at this time
Quantity of Fenbendazole 150mg requested to be sent through InsulinHub.com portal*

Fenbendazole 150mg x 100 tablets @ $125Fenbendazole 150mg x 200 tablets @ $225Fenbendazole 150mg x 300 tablets @ $325Fenbendazole 150mg x 400 tablets @ $425Fenbendazole 150mg x 500 tablets @ $499nothing at this time
Quantity of Fluconazole 150mg requested to be sent through InsulinHub.com portal*

Fluconazole 150mg x 30 tablets @ $25Fluconazole 150mg x 60 tablets @ $45Fluconazole 150mg x 90 tablets @ $65Fluconazole 150mg x 180 tablets @ $125nothing at this time
Quantity of Hydroxychloroquine 200mg requested to be sent through InsulinHub.com portal*

HCQ 200mg generic or brand x 60 tablets @ $99HCQ 200mg generic or brand x 120 tablets @ $175HCQ 200mg generic or brand x 180 tablets @ $235HCQ 200mg generic or brand x 450 tablets @ $399nothing at this time
Quantity of Ivermectin 12mg requested to be sent through InsulinHub.com portal - LIMITED TIME SALE FOR MAY - WE DOUBLE QUANTITIES REQUESTED*

Ivermectin 12mg x 28 tablets @ $99Ivermectin 12mg x 56 tablets @ $175Ivermectin 12mg x 84 tablets @ $235Ivermectin 12mg x 140 tablets @ $399Ivermectin 12mg x 280 tablets @ $599Ivermectin 12mg x 420 tablets @ $799nothing at this time
Quantity of Mebendazole 100mg requested to be sent through InsulinHub.com portal*

Mebendazole 100mg x 60 tablets @ $199Mebendazole 100mg x 120 tablets @ $375Mebendazole 100mg x 180 tablets @ $525Mebendazole 100mg x 240 tablets @ $675nothing at this time
Quantity of Metronidazole 400mg requested to be sent through InsulinHub.com portal*

Metronidazole 400mg x 100 tablets @ $29Metronidazole 400mg x 200 tablets @ $39Metronidazole 400mg x 300 tablets @ $49Flagyl 400mg (BRAND by Abbott) x 100 tablets @ $39Flagyl 400mg (BRAND by Abbott) x 200 tablets @ $69Flagyl 400mg (BRAND by Abbott) x 300 tablets @ $99nothing at this time
Quantity of Nitazoxanide 500mg requested to be sent through InsulinHub.com portal*

Nitazoxanide 500mg x 24 tablets @ $175Nitazoxanide 500mg x 48 tablets @ $325Nitazoxanide 500mg x 98 tablets @ $599Nitazoxanide 500mg x 120 tablets @ $699nothing at this time
Quantity of Nitrofurantoin 100mg requested to be sent through InsulinHub.com portal*

Nitrofurantoin 100mg x 90 tablets @ $95Nitrofurantoin 100mg x 180 tablets @ $175Nitrofurantoin 100mg x 270 tablets @ $235nothing at this time
Quantity of Sulfamethoxazole/Trimethoprim 800/160mg requested to be sent through InsulinHub.com portal*

Sulfamethoxazole/Trimethoprim 800/160mg x 200 tablets @ $75Sulfamethoxazole/Trimethoprim 800/160mg x 400 tablets @ $125nothing at this time
Describe fully the name, strength, and directions of use for the "other" medicine requested*
I understand that these medicines are manufactured in India (unless otherwise specified) and will be shipped directly from India. I also accept that shipping times will take an average 3 weeks once payment is received.*

I acknowledge
I understand that InsulinHub.com is given full permission to this form immediately and will confirm my order. I understand that my order may be cancelled for any reason prior to acceping payment.*

I acknowledge
I hereby confirm that all questions were answered accurately and I hold harmless all pharmacy and medical providers. I have approached this medical provider myself as if personally in his office in the country of his practice, requesting a specific medication for the purpose given. I will not take the medicine itself unless I am advised by a local physician directly. I also hold harmless the pharmacy and website platform by which I found this medicine and am completing this order. I take full personal responsibility for my decision to consult with a foreign medical service and to receive this medicine from that same jurisdiction.*

I acknowledge
My preference for payment (Visa/MC)

I will call InsulinHub at 1-718-312-8727I will visit InsulinHub on their secure LiveChat at https://direct.lc.chat/12078399/I prefer for InsulinHub to contact me directlyInsulinHub already has my billing information
How did you hear about us?
Be as specific as possible
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Antibiotic Prep Program

General Information

Medical History

Medicine Requested