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Your First and Last name:
I have used and need to reorder the following prescription medications:
Azithromycin 250mg
Gentamycin Ophth Soln
I have used and need to reorder the following non-prescription medications:
Acetaminophen 325mg
MediPhenyl
Hydrocortisone Cream
Bacitracin Ointment
Senna Tablets
Loperamide 2mg
Misc. Bandages
Disposible Thermometer
Mosquito Towelettes
Meclizine 25mg
Diphenhydramine 25mg
Tolnaftate Cream
Cepastat Lozenge
Pepto Bismol Tablets
Onset Forte
Condom
Mosquito Repellant, 2oz
Hand Sanitzer
Antiseptic Wipes
CPR Barrier Mask
Steri Strips
Emergency Dental Kit
Misc. Syringes and Needles
Sutures
Wound Dressings
Please update your address if anything has changed since you last received you travel kit:
Address
City, State, Country, Zip
Phone
Please update your medical information if anything has changed since you last received your travel kit:
Medication Allergies
Medication Allergies cont...
Med Conditions (diabetes, asthma, etc)
Conditions cont...
By submitting order, I understand that if I am pregnant I should NOT take any of the medications in this kit without first consulting my physician. I further state that I am a Chevron employee with authorization to travel and reorder medication.
Bellegrove Pharmacy | 1535 116th Ave. NE, Bellevue, WA 98004 | (800) 446-2123
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