IMC Pharmacy Refill Request

"*" Fields Required.
Destination*
Length Of Stay
Departure Date mm/dd/yyyy
Traveler Information
First Name*
Last Name*
Home Address*
Address:
Suite, Apt, Box, etc:
City:
Province / State:
Postal / Zip Code:
Phone* xxx-xxx-xxxx
Email
Date of Birth* mm/dd/yyyy  Age:
Height And Weight*Height:  Feet  Inches  Weight: Pounds 
BMI:
Please enter height and weight to calculate BMI.
Company
Cost Center / Job Number
Patient Information Update
New Medical Problems
Current Medications
Allergies
 Other: 
Chronic Disorders
 Other: 
Medication Kit Supplied / Requested
Med Kit
Meds/Supplies*  Azithromycin / Zithromax 
 Cipro / Ciprofloxacin 
 DEET 
 Doxycycline 
 Epi-Pen 
 Flagyl / Metronidazole 
 Lariam / Mefloquine 
 Tramadol 50mg** 
 Malarone / Atovaquone-Proguanil 
 N-95 Respiratory mask 
 Permethrin 
 Relenza / Zanamivir 
 Tamiflu / Oseltamivir 
 Temazepam** 
 Zolpidem / Ambien CR** 
 Zolpidem / Ambien** 

**Note: These medications are controlled substances and may require a brief physician encounter for refills.
Other Medication Requested
Where will you be picking up the medications?