Prophylactic Treatment for Lyme Disease (Form L)

LYME DISEASE

Prophylactic Treatment
Information collected on this form will be used to document the need and authorization of prophylactic (preventive) treatment of Lyme Disease

Part 1: Personal Information
Full Name*
Date of Birth*

MonthDayYear
Date
Address*

Address

Street Address Line 2

City StateState / Province

Zip
Phone*
Gender*

MaleFemale
Are you currently pregnant?

YesNo
Are you currently breastfeeding?

YesNo
We are sorry!

Taking doxycycline while you are pregnant and/or nursing is not advised, and our collaborative practice agreement doesn't allow other medications to be used in its place. Please note that other prophylactic treatments may be available to you, but you will have to contact your primary care provider to discuss those options.

Thank you for choosing us as your first stop to receive treatment!

Part 2: Questions for person receiving treatment
What age bracket do you fit into?*

0-7 years8-17 years18+ years
We are sorry!

Unfortunately, our collaborative practice agreement doesn't allow us to prophylactically treat children under the age of 8 with doxycycline. Please reach out to your pediatrician for further instruction.

Thank you for choosing us as your first stop to receive treatment!
Does the minor weigh over 100lbs?

YesNo
Weight (in lbs)
Have you ever had an adverse drug reaction to doxycycline?*

YesNo
Please describe your reaction (symptoms, etc)

Part 3: Questions regarding incident
Did the tick bite occur in a state or county where Lyme Disease is prevalent (per CDC data surveillance). *Please note: this includes all of Wisconsin and the upper peninsula of Michigan**

YesNo
We are sorry!

Answering "no" to this question makes you ineligible for this service. The tick bite must have occurred in an area of the country that Lyme Disease is prevalent in order to receive this prophylactic treatment.

Thank you for choosing us as your first stop to receive treatment!
Has the attached tick been identified to be an adult or nymphal blacklegged or deer tick? See above image for reference.*

YesNo
We are sorry!

Answering "no" to this question makes you ineligible for this service. The tick that bit you must have been identified as a blacklegged or deer tick to receive this prophylactic treatment.

Thank you for choosing us as your first stop to receive treatment!
Was the tick attached to your body for at least 36 hours, based on degree of tick engorgement with blood or likely time of exposure to the tick? See above image for reference.*

YesNo
We are sorry!

Answering "no" to this question makes you ineligible for this service. The tick that bit you must have been attached to your body for at least 36 hours to receive this prophylactic treatment.

Thank you for choosing us as your first stop to receive treatment!
Was the tick removed from your body within the last 72 hours?*

YesNo
We are sorry!

Answering "no" to this question makes you ineligible for this service. The tick that bit you must have been removed in the last 72 hours (3 days) to receive this prophylactic treatment.

Thank you for choosing us as your first stop to receive treatment!

Part 4: Payment and Consent
Consent:

By signing below, I confirm that I have completed the above form to the best of my knowledge and abilities

I understand the prescription is to be prepared by and picked up at Tomahawk Pharmacy. If unable to pick up at Tomahawk Pharmacy, please call us to possibly make other arrangements.

I understand I am responsible for any copay associated with the prescription after the claim is submitted to my insurance(s), if any. If no insurance is available, the prescription will charged as our Tomahawk Pharmacy cash price.
Signature*

Clear
Date

MonthDayYear
Date

My Products

Post-Tick Bite Doxycycline Treatment

$20.00

Enter coupon

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Paid online*

Yes
Should be Empty:

LYME DISEASE