Prescription Intake | D&D Pharmacy

Personal information

Enter your legal name and contact details exactly as they appear on your government-issued ID.

Fields marked * are required. Your information is transmitted securely and handled in accordance with HIPAA.

Legal first name *

Legal last name *

Date of birth *

Sex assigned at birth *

Height / weight

Contact

Email address *

Phone number *

Florida address *

Must be a Florida address. Fla. Stat. §456.47 requires patients to be in Florida at time of telehealth consult.

Identity verification

Government-issued ID type *

ID number *

Your ID number is used only for identity verification as required under Florida telehealth law and is not stored after verification.

Telehealth & privacy consents

Florida law requires your informed consent before telehealth services may be provided. Please read each section carefully.

All three consents below are required before a physician can review your intake. Controlled substances (Schedule II–V, including benzodiazepines) cannot be prescribed via telehealth without a prior in-person exam under Florida law.

Electronic signature

Type your full legal name to sign electronically *

By typing your name you apply a legally binding electronic signature under UETA and the federal E-SIGN Act.

Today's date *

Your trip

Travel destination and activities help the physician select the most appropriate medications for your kit.

Destination country / region(s) *

Departure date *

Return date *

Trip type

Primary travel type *

Urban / resort Adventure / outdoor Cruise Rural / remote Business Mission / volunteer

Planned activities — check all that apply

Hiking / trekking Swimming / water sports Wildlife / animal contact High altitude (>8,000 ft) Scuba diving Street food / local markets Visiting medical facilities Limited / no access to care

Travel history & prophylaxis

Have you traveled to this destination before?

Yes No

Are your routine travel vaccinations up to date? (Hep A/B, typhoid, tetanus, etc.)

Yes No Not sure

Are you taking or planning malaria prophylaxis?

Yes No Need advice

Health conditions

Check all current or past conditions. This allows the physician to screen for contraindications and adjust your kit accordingly.

Cardiovascular

Long QT syndrome / QTc prolongation Cardiac arrhythmia (any type) Hypertension Heart failure

Respiratory

Asthma COPD / emphysema

Gastrointestinal

Prior C. difficile infection IBD (Crohn's / ulcerative colitis) Liver disease / cirrhosis History of GI bleeding

Renal & metabolic

Chronic kidney disease Currently on dialysis Diabetes (type 1 or 2) G6PD deficiency

Neurological & musculoskeletal

Seizure disorder / epilepsy Myasthenia gravis Prior tendon rupture / tendinopathy Psychiatric condition

Immune & other

Immunocompromised (HIV, transplant, chemo) Active cancer Prior anaphylaxis (any cause) None of the above

Reproductive health

Are you currently pregnant or trying to become pregnant? *

Yes No Not applicable

Are you currently breastfeeding?

Yes No Not applicable

Are you using oral contraceptives or hormonal birth control?

Yes No

Surgical & hospitalization history

Any hospitalizations or surgeries in the past 12 months?

Yes No

Date of last physical exam

Medications & allergies

Accurate allergy and medication information is critical. Some allergies block prescribing of specific kit medications.

The allergies below map directly to medications in the travel kit. Check all that apply — each triggers a physician review before prescribing.

Drug allergies

Describe any allergic reactions — type and severity

Any other drug, food, or environmental allergies

Current prescription medications

List all current prescription medications, doses, and frequencies

Any antibiotics taken in the past 3 months?

Yes No

If yes, which antibiotic and for what condition

OTC medications & supplements

Regular OTC medications

Vitamins and supplements

Are you taking any blood thinners? (warfarin, Eliquis, Xarelto, Plavix)

Yes No

Drug interaction screening

These questions target specific contraindications for the medications commonly included in travel kits. Answering "yes" to any item flags your intake for closer physician review — it does not automatically disqualify you.

Cardiac & QTc screening

Azithromycin and ondansetron can prolong the QT interval and trigger arrhythmias in susceptible patients.

Have you ever been told you have a prolonged QT interval, or been advised to avoid certain antibiotics due to heart rhythm concerns?

Yes No Unsure

Are you currently taking any QT-prolonging medications? (antipsychotics, certain antidepressants, antiarrhythmics, some antifungals)

Yes No Unsure

Do you have low potassium or magnesium, or take diuretics?

Yes No Unsure

Steroid contraindications

Do you have active peptic ulcer disease, uncontrolled diabetes, or an active systemic infection?

Yes No

Have you taken oral or injected corticosteroids in the past 3 months?

Yes No

Antifungal & metronidazole interactions

Do you drink alcohol? (Metronidazole causes a severe disulfiram reaction with alcohol)

Yes No

Are you taking any CYP3A4-interacting medications? (certain statins, HIV antiretrovirals, tacrolimus, cyclosporine, some benzodiazepines)

Yes No Unsure

Oseltamivir & doxycycline

Have you ever had an adverse reaction to Tamiflu (oseltamivir)?

Yes No Never taken it

Do you have a history of esophageal problems or difficulty swallowing? (Doxycycline can cause esophageal ulceration if not taken with sufficient water)

Yes No

Additional notes

Anything else the prescribing physician should know

Do you have a primary care physician?

Yes No

If yes, provider name and practice — optional, for records coordination

Delivery & emergency contact

Your kit will be dispensed and shipped directly by D&D Pharmacy to the Florida address you provided. Let us know how you'd like to receive it and who to contact in an emergency.

Delivery preference

How would you like to receive your kit? *

Ship to me Delivered to the Florida address on file. Ships in 3–5 days once authorized. In-store pickup Pick up at 9787 SW 72nd St, Miami. Ready within 24 hrs of authorization.

Emergency contact

Emergency contact name

Relationship

Emergency contact phone

Review & submit

Please review your information before submitting. A licensed Florida physician will evaluate your responses and contact you within 1 business day.

Complete all steps to preview your summary here.

Start your prescription intake.

Personal information

Telehealth & privacy consents

Your trip

Health conditions

Medications & allergies

Drug interaction screening

Delivery & emergency contact

Review & submit

Intake form submitted

What to expect

Privacy & security

Questions?

Florida telehealth notice