HELP FIND MY KIT

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Are you 18 years or older?* This field is required.
Yes
No
4
In which state do you live?* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
D.C.
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
None of the Above / I do not live in the U.S.
5
Are you interested in obtaining prescription medications ahead of time for travel use, outdoor adventure, remote living, or emergency preparedness purposes?
Yes
No
6
Are you interested in obtaining prescription medications ahead of time for any of the following? (Click all that apply) travel use, outdoor adventure, remote living, or emergency preparedness purposes?
Outdoor Adventure
Travel Use
Personal Preparedness / Emergency Situations
Other
7
Do you have a specific condition for which you need prescription medication on hand quickly, even when you are away from home? (Asthma, frequent UTI's, Allergic Reaction, etc)* This field is required.
Yes
No
8
Do you plan to travel at sea or travel to altitudes of 8,000 or more in the next 12 months?* This field is required.
Sea
Altitude
Both
Neither
9
Do you have an allergy to any medications?* This field is required.
I have No Known Medication Allergies
I have an Allergy to one or more Medications
10
If yes, choose one or more selections below* This field is required.
Penicillin (Amoxicillin)
Tetracyclines (Doxycycline, etc)
Macrolides (Azithromycin, etc)
Fluoroquinolones(Cipro, etc)
Cephalosporins (Cephalexin,etc.)
Trimethoprim/Sulfamethoxazole(Bactrim)
Other SULFA drugs
NSAIDs (Ibuprofen, Naproxen) or Aspirin
Other
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