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Medical Kits Aplication

First & Last Name

Home Address

*

City, State, Zip Code

*

Date of Birth

*

Cell Phone #

*

Email Address

*

Weight

*

Height

*

Which kit are you applying for?

*

Untitled multiple choice field

A

Annual Parasite Purge Package

B

Emergency Medical Kit

C

Ivermectin 12 mg – 90 Capsules

D

Fenbendazole 222 mg – 90 Capsules

E

Cancer Protocol – One Month Supply

F

Cyclospora Outbreak Kit

G

Glutathione Injections (GHS)

H

Low Dose Naltrexone (LDN)

Main Complaint

*

List any medical problems

*

List Allergies

*

List of Current medication

*

Currently Hospitalized?

*

Taking Coumadin or Warfarin?

*

Do you Smoke or Vape?

*

Any Current Symptoms?

*

Thank you. Our team will reach out to you shortly after reviewing your information.