Adult Elite Kit

Adult Elite Kit

(For individuals 100 pounds and up) - 16 Medications Welcome! Let's get started!
Have you bought a kit from us before?*

No, New PatientYes, Existing Patient

This form is for the Adult Elite Kit*
If you are wanting a different kit please back out of this form and choose the kit you are intending to purchase.

Which state do you live in? *
At this time we can only accept patients in Utah, Idaho, and Wyoming.

Are you buying a kit for yourself or for a minor child under the age of 18?*

Patient Name - Enter your name as it appears on your government issued ID*

First NameMiddle NameLast NameSuffix

Patient Name - Enter patients name who is a minor under the age of 18 years of age*

First NameMiddle NameLast NameSuffix
Name of legal guardian*

First NameMiddle NameLast NameSuffix

Date of Birth *

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code

Weight (pounds)*
Gender*

Have you had a routine visit with your primary care provider in the last two years? *
We want to make sure that you don't have any undiagnosed conditions and are generally healthy.

Do you have any medication allergies?*

If Yes, please list all allergies followed by the type of reaction you have to them.*

Do you have any chronic health conditions?*

Please list any chronic health condition.*

Are you currently taking any medications or supplements?*

Please list all medications and supplements currently being taken.*

Have you been diagnosed with liver or kidney disease?*

Do you have diabetes?*

Are you currently pregnant?*

By Clicking Agree you agree to the following statements:

I have answered all the questions truthfully and to the best of my knowledge.

I have answered the questions as the patient or on behalf of my minor child, who is the patient.

I understand that this kit is only for the intended person (patient) and is not to be shared with anyone else including family and friends.

I understand that this kit is to be used as a last resort and does not replace seeking health care treatment whenever possible.

I understand that if my symptoms were to worsen that I should stop treatment and seek care from a medical professional.

I understand that if I experience any symptoms of allergic reaction that I should stop treatment and seek emergency care.

I understand that if I am pregnant or become pregnant that I must consult with my medical provider before the use of any of these medications.

I agree to keep all medication out of the reach of children.

I understand that this medication is for emergency preparation purposes and is not intended to treat a current condition or diagnosis.

I understand that this does not replace annual primary care evaluations.

I will use this medication under the guidance of a medical professional whenever possible.

I understand that by clicking the submit button at the end of this form that I agree to have my payment processed when and if approved for this kit which may occur at any time within 6 days of submitting this form.

I understand that all sales are final and that there are no refunds or returns.
Do you agree to the above statements as patient or on behalf of minor child.*
Signature*

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What to expect:
- Once you press the submit button our healthcare providers will receive your medical history.
- Our medical providers will review your health history and decide if this kit is the right fit for you.
- We may need to get in touch with you if we need clarification. We may call or email you if substitutions are possible.
- If approved your payment will be processed and you will receive a receipt through email. Payment may be processed up to 6 days after this form is submitted.
- This kit may not be appropriate for everyone. Some requests will be denied for safety reasons and payment will not be processed in those situations.
- All sales are final.
- Once purchased we will send your information to our partnered pharmacy where your kit will be dispensed.
- Shipping and tracking information will be provided via your Square receipt as it is updated, after your kit is sent out from the pharmacy.
- Please allow up to 7 business days to receive your kit.
High Creek Pharmacy

609 South Hwy 91

Richmond, UT 84338

Email: info@highcreekpharmacy.com

Phone: (435) 258-5560

Fax: (435) 258-5538

Dx: Encounter for Prophylactic Measures, Z29.9

Treatment:

O This patient has a high safety profile and the included medications are considered very safe for use in appropriate situations.

O This patient has a high safety profile with the following substitutions required:

O This patient is not a safe candidate for this product.

Rx:

Amoxicillin-Pot Clavulanate Tablet, 875-125 MG, 1 tablet, Orally, every 12 hrs, 10 day(s), 20 Tablet

Azithromycin Tablet, 250 MG, 2 tablet on the first day, then 1 tablet daily for 4 days, Orally, Once a day, 5 day(s), 6 Tablet

Cipro Tablet, 500 MG, 1 tablet, Orally, every 12 hrs, 10 day(s), 20

Doxycycline Hyclate Capsule, 100 MG, 1 capsule, Orally, Twice a day, 10 day(s), 20 Capsule

metroNIDAZOLE Tablet, 500 MG, 1 tablet, Orally, Twice a day, 7 days, 14 Tablet

Amoxicillin Capsule, 500 MG, 2 capsules, Orally, every 12 hrs, 10 day(s), 40 Capsule

Sulfamethoxazole-Trimethoprim Tablet, 800-160 MG, 1 tablet, Orally, Twice a day, 10 day(s), 20 Tablet

Cephalexin Capsule, 500 MG, 2 capsule, Orally, every 12 hrs, 10 day(s), 40 Capsule

Medrol Tablet Therapy Pack, 4 MG, as directed, Orally, Once a day, 6 days, 21 Tablet

Ondansetron Tablet Disintegrating, 4 MG, 1 tablet on the tongue and allow to dissolve, Orally, Q6-8 hours, 3 days, 15 Tablet

Albuterol Sulfate HFA Aerosol Solution, 108 (90 Base) MCG/ACT, 2 puffs as needed for asthma, Inhalation, every 4 hrs, 1 Inhaler

Clindamycin HCl Capsule, 300 MG, 1 capsule, Orally, BID, 7 days, 14 Capsule

Diflucan Tablet, 150 MG, 1 tablet, Orally, q48hr, 2 days, 2 tablets

Ibuprofen Tablet, 800 MG, 1 tablet with food or milk as needed, Orally, Three times a day, 10 days, 30 Tablet

predniSONE Tablet, 20 MG, 3 tabs once daily, Orally, Once a day, 5 days, 15 Tablet

Triamcinolone Acetonide Cream, 0.1 %, 1 application, Externally, Twice a day, 7 day(s), 60 Gram

Substitutions:

Prescriber Name: Jacob Anderson DNP, FNP-c

Prescriber NPI: 1316329220

Prescriber Signature:

Adult Elite Kit

Included:

16 personal prescription medications
Medication substitutions available for allergies
1 Hard case
2 Moisture resistant on the go storage bags
1 Printed Tough Luck Treatment Guide - conditions, treatment, and helpful information
1 Printed Quick Card - Medication outline
1 Year of support through email - info@toughluckmedkits.com
Free Shipping

Medications Included in the Adult Elite Kit:

1. ALBUTEROL INHALER
2. AMOXICILLIN 500MG CAP
3. AMOXICILLIN/CLAVULANATE 875/125MG
4. AZITHROMYCIN 250MG (Z-PACK)
5. CEPHALEXIN 500MG (KEFLEX)
6. CIPROFLOXACIN 500MG (CIPRO)
7. CLINDAMYCIN 300MG
8. DOXYCYCLINE 100MG CAP (DOXY)
9. FLOCONAZOLE 150MG (DIFLUCAN)
10. IBUPROFEN 800MG
11. METHYIPREDNISOLONE 4MG DOSE PACK (MEDROL)
12. METRONIDAZOLE 500MG (FLAGYL)
13. ONDANSETRON 4MG ODT (ZOFRAN)
14. PREDNISONE 20MG
15. TRIAMCINOLONE 0.1% CREAM
16. TRIMETHOPRIM/SULFAMETHOXAZOLE 800/160MG (BACTRIM DS)

My Products*

Adult Elite KitThis kit includes 16 personal prescription medicines, a quick reference card, and a printed copy of the Tough Luck Treatment Guide.

$394.00

Enter coupon

Total

$0.00

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