Adult Mini Kit

Adult Mini Kit

(For individuals 100 pounds and up) - 3 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 Mini 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 medication 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*

Clear

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:

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 Tablet

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

Substitutions:

Prescriber Name: Jacob Anderson DNP, FNP-c

Prescriber NPI: 1316329220

Prescriber Signature:

Adult Mini Kit

Included:

3 Personal prescription medications
Medication substitutions available for allergies
1 Moisture resistant on the go storage bag
Email pdf version - 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

Not Included:

Hard Case
Printed Tough Luck Treatment Guide - (PDF version included through email)

Medications Included in the Adult Standard Kit:

1. AMOXICILLIN 500MG CAP
2. AZITHROMYCIN 250MG (Z-PACK)
3. CIPROFLOXACIN 500MG (CIPRO)

My Products*

Adult Mini kit This kit includes 3 personal prescription medicines, a quick reference card, and the Tough Luck Treatment Guide PDF.

$95.00

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Afterpay

Should be Empty: