Ivermectin Screening Form | Village Pharmacy TN

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IVERMECTIN SCREENING RISK ASSESMENT TOOL

First name

Phone

Last name

Date of Birth

Email

Patient's Weight

Street Address

State

Street Address Line 2

Postal / Zip code

City

Primary Care Physician / Provider

Do yo have any medical conditions(comorbidities)?

Yes

No

If yes, please list below:

Are you or could you be pregnant or breastfeeding? *

Yes, If yes then you cannot obtain ivermectin through this agreement.

No

Are you prescribed or using any of the following medicatins: *

Yes, If yes then you cannot obtain ivermectin through this agreement.

No

--------------------

Coumadin/warfarin (blood thinner)

Sirolimus/Rapamune (anti-rejection organ transplant meds, immunosuppressant)

Erdafitnib/Balversa (cancer drug for bladder/urinary cancer)

Lasmiditan/Reyvow (migraine med)

Tepotinib/Tepmetko (small cell lung cancer med)

Erythromycin ethylsuccinate, lactobionate, or sterate (antibiotic)

Itraconazole (anti-fungal med)

Ketaconazole (anti-fungal med)

Rifampin/Rifadin (anti-Tuberculosis med)

Verapamil (blood pressure/heart rythm med)

I am 18 years old or older

Which Village Pharmacy location for pickup

I,

agree to voluntarily obtain ivermectin from this pharmacy under the collaborative pharmacy agreement established by the State of Tennessee TCA 63-10-908 and attest that the above personal information is accurate.

Your Signature

Today's Date

Thank you!

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