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

Full Name
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

City StateState / Province

Zip
Phone
Format: (000) 000-0000.
Gender
Are you currently pregnant?
Are you currently breastfeeding?
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!

What age bracket do you fit into?
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?
Weight (in lbs)
Have you ever had an adverse drug reaction to doxycycline?
Please describe your reaction (symptoms, etc)

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*
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.
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.
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?
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!

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
Date

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Date

My Products

Post-Tick Bite Doxycycline Treatment

$20.00

Shipping (optional)

If you are unable to come to Tomahawk Pharmacy to pick up your antibiotic, we can ship it to you at the address you supplied. Please note: any requests placed after 12:00pm won't get shipped until the next business day (if after 12:00pm on Friday, it won't get shipped until Monday). The pharmacy is not responsible for how long shipping will take nor any delay in treatment due to shipping.

$15.00

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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

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LYME DISEASE

My Products