Pre-Qualification Form

Pre-Qualification Form

Answer these simple questions to see if you are eligible to purchase one of our kits!
Name*

First NameLast Name
Email*
example@example.com
Are you 18 years or older?*

YesNo
In which state do you live?*
Do you agree with the following statement? "I am able to read and understand instructions, and I do not anticipate any difficulty understanding instructions in the Medication Guide on how to take a medication in my kit"*

I agreeHuh?
Are you interested in obtaining prescription medications ahead of time for travel use, outdoor adventure, remote living, or emergency preparedness purposes?*

YesNo
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)*

YesNo
Do you plan to travel at sea or travel to altitudes of 8,000 or more in the next 12 months?*

SeaAltitudeBothNeither
Do you have an allergy to any medications?*

I have No Known Medication AllergiesI have an Allergy to one or more Medications
If yes, choose one or more selections below*

Penicillin (Amoxicillin)Tetracyclines (Doxycycline, etc)Macrolides (Azithromycin, etc)Fluoroquinolones(Cipro, etc)Cephalosporins (Cephalexin,etc.)Trimethoprim/Sulfamethoxazole(Bactrim)Other SULFA drugsNSAIDs (Ibuprofen, Naproxen) or AspirinOther
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