Child Elite Form

Child Elite Kit

11 Medications (Age 2+ and Under 100 pounds) Welcome! Let's get started!
Have you bought a kit from us before?*

No, New PatientYes, Existing Patient

This form is for the Child 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.

Patient Name - Enter name of minor child 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*

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

Does your child have any medication allergies?*

If Yes, please list all allergies followed by the type of reaction your child has to them.*

Does your child have any chronic health conditions?*

Please list any chronic health conditions.*

Is your child currently taking any medications or supplements?*

Please list all medications and supplements your child is currently taking.*

Has your child been diagnosed with liver or kidney disease?*

Does your child have diabetes?*

Is your child pregnant?*

By Clicking Agree you agree to the following statements:

As legal guardian of minor child (patient) I have answered all the questions truthfully and to the best of my knowledge.

As legal guardian I have answered the questions on behalf of my minor child, who is the patient.

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

I understand as legal guardian that if my minor child's symptoms were to worsen that treatment should be stopped and that you should seek care from a medical professional.

I understand that if my minor child should experience any symptoms of allergic reaction that treatment should be stopped and that you should seek emergency care.

I understand that if my minor child is pregnant or becomes pregnant that a medical provider will be consulted before the use of any of these medications.

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

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

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

As legal guardian I will give this medication under 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 legal guardian and on behalf of minor child (patient). *
Signature*

Clear

What to expect:
- Once you press the submit button our healthcare providers will receive your child's medical history.
- Our medical providers will review your child's health history and decide if this kit is the right fit for your child.
- 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 child's 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 child's 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 Suspension Reconstituted, 400 MG/5ML, as directed, Orally, 2 bottles concentrate

Azithromycin Suspension Reconstituted, 200 MG/5ML, as directed, Orally, Once a day, 5 day(s), 2 bottles concentrate

Cephalexin Suspension Reconstituted, 250 MG/5ML, as directed, Orally, every 12 hrs, 4 day(s), 1 bottle concentrate

Ciprofloxacin HCl Solution, 0.3 %, 1 drops into eye, Ophthalmic, Three times per day, 7 days, 5 Milliliter

prednisoLONE Solution, 15 MG/5ML, as directed, Orally, Once a day, 3 days, 30 ml

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

Dexamethasone Tablet, 4 MG, as directed, Orally, Once a day, 3 days, 9 Tablet

Mupirocin Ointment, 2 %, 1 application, Externally, Three times a day, 5 days, 30 gram tube

Nystatin-Triamcinolone Cream, 100000-0.1 UNIT/GM, 1 application, Externally, Twice a day, 7 days, 60 Gram tube

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

Sulfamethoxazole-Trimethoprim Suspension, 200-40 MG/5ML, as directed, Orally, twice a day, 1 bottle suspension

Substitutions:

Prescriber Name: Jacob Anderson DNP, FNP-c

Prescriber NPI: 1316329220

Prescriber Signature:

Child Elite Kit

Included:

11 personal prescription medications
Liquid form easy to swallow (Follow our Quick Card Medication Outline for easy mixing)
Medication substitutions available for allergies
1 Hard case
2 Moisture resistant child proof 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 Child Elite Kit:

1. ALBUTEROL INHALER
2. AMOXICILLIN SUSPENSION 400/5ML@ 80MG/KG/DAY
3. AZITHROMYCIN SUSPENSION 200/5ML @ 12MG/KG/DAY
4. CEPHALEXIN SUSPENSION 200MG/5ML @40MG/KG/DAY
5. CIPROFLOXACIN 0.3% OPHTHALMIC DROPS
6. DEXAMETHASONE 4MG TAB
7. MUPIROCEN OINTMENT
8. NYSTATIN-TRIAMCINOLONE COMBO (PINK CREAM)
9. ONDANSETRON 4MG ODT (ZOFRAN)
10. PREDNISOLONE SUSPENSION 15MG/5ML @ 1MG/KG/DAY
11. SULFAMETHOXAZOLE-TRIMETHOPRIM SUSPENSION @8MG/KG (SULFATRIM PEDIATRIC SUSPENSION)

My Products*

Child Elite KitThis kit includes 11 personal prescription medicines, a quick reference card, and a printed copy of the Tough Luck Treatment Guide.

$380.00

Enter coupon

Total

$0.00

Payment Methods

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