Traveler’s supply custom kit worksheet

CUSTOM MEDICAL KIT
Organization:
Number: Email:
How many people will use this kit?
Trip Duration:
Quantity of kits to be ordered:
Destination (please check one):
_____ Developed Country
_____ Developing Country
… Check here if you want a medical advisor to provide consultation on this order.
Please indicate the products and quantities desired. If you do not see what you want listed, please use the blank lines at the end to notify us of your needs. Fax form to 410-453-6301. We will contact you within one business day.
CATEGORY DESCRIPTION
QUANTITY
BANDAGES
4” x 5 ½yds Elastic Bandage with Velcro 1” x 5yds Tearable Self-Adhering Wrap (Medi-Rip) 2” x 5yds Tearable Self-Adhering Wrap (Medi-Rip) 3” x 5yds Tearable Self-Adhering Wrap (Medi-Rip) CATEGORY DESCRIPTION
QUANTITY
4” x 5yds Tearable Self-Adhering Wrap (Medi-Rip) 1” x 5yds Conforming Gauze Non-Sterile 2” x 5yds Conforming Gauze Non-Sterile 3” x 5yds Conforming Gauze Non-Sterile 4” x 5yds Conforming Gauze Non-Sterile WIPES &
TOWELETTES
CATEGORY DESCRIPTION
QUANTITY
MEDICATIONS
Pain Relief
500mg Acetaminophen (Extra-Strength Tylenol) 500mg acetaminophen; 5mg Phenylephrine HCL; 75mg Caffeine 250 mg Aspirin; 250mg Acetaminophen; 65mg Caffeine ( Excedrin) 290mg Magnesium Salicylate; 250mg Acetaminophen; 50mg Caffeine Cough/Cold & Flu
325mg acetaminophen 30mg Pseudoephedrine HCL 10mg Phenylephrine HCL; 325mg Acetaminophen; 200mg Guaifenesin; 32.5mg Caffeine 325mg Acetaminophen; 200mg Guaifenesin; 10mg Phenylephrine HCL Cough & Sore Throat
CATEGORY DESCRIPTION
QUANTITY
0.5mg Cetylpyridinium Chloride (Cepacol) Allergy Cold & Flu
325mg Acetaminophen; 2mg Chlorpheniramine Maleate; 5mg Phenylephrine HCL 4mg Chlorpheniramine Maleate (Chlor-Trimeton) 162.5mg Acetaminophen; 2mg Chlorpheniramine Maleate; 5mg Phenylaphrine HCL Antacids, Stomach &
Diarrhea Relief
300mg Calcium Carbonate; 40mg Simethicone 262mg Bismuth Subsalicylate (Pepto-Bismol Tablets) 25mg Meclazine Hydrochloride (Dramamine Less Drowsy) Women’s Health
500mg Acetaminophen; 25mg Pamabrom (Tylenol Menstrual Relief) 500mg Acetaminophen; 50mg Pamabrom: Plus Vitamins E 50 I.U.; B1 5mg; B2 5mg; B6 50mg; C 50mg; Niacinamide 5mg; Folic Acid 100mg; and Magnesium 50mg InstyDose Liquid One-
Dose Tubes
1200mg Aluminum Hydroxide; 1200mg Magnesium Hydroxide; 120mg Simethicone CATEGORY DESCRIPTION
QUANTITY
2400mg Aluminum Hydroxide; 2400mg Magnesium Hydroxide; 240mg Simethicone (Mylanta Double Strength) 1.87g Dextrose; 1.87g Levulose; 21.5mg Phosphoric Acid (Emetrol) 200mg Guaifenesin; 20mg Dextromethorphan Hydrobromide (Robitussin DM) 200mg Guaifenesin; 20mg Dextromethorphan Hydrobromide TOPICALS AEROSOL Blood Clotting Spray 3oz Can
TOPICALS PUMP
SRAYS & LIQUIDS
Safetec Isopropyl Alcohol Spray Pump 2oz bottle Safetec Hydrogen Peroxide Spray Pump 42oz bottle Safetec Cut & Scrape Cleaner Spray Pump 2oz bottle APPLICATORS
6” Sterile Cotton Tipped Applicators 2-Pack 0.4ml Refresh Plus 0.5% Sterile Single-Use Containers HOT/COLD PACKS
CATEGORY DESCRIPTION
QUANTITY
BIOSAFETY
INSTRUMENTS
NEEDLE/SYRINGE/
CATEGORY DESCRIPTION
QUANTITY
SKIN PROTECTION
2oz Ultrathon 33% DEET Insect Repellent Rated #1 THERMOMETERS
REHYDRATION
Kwickpoint Medical Visual Language Translator
We can also supply any prescription medication based on your physician’s or organization’s
medical director’s approval. Please indicate below, and a representative will contact you within
one business day.
ADDITIONAL
REQUESTS
Please add any additional requests. Feel free to contact us by phone at 410-453-6300, fax at 410-

Source: http://www.medexassist.biz/Products/Travel/CustomizedKitForm.pdf