Head of Household Medication Dispensing Form The intent of this form is to collect information for the Head of Household and any other individuals that reside in that household during a public health emergency. The form serves as a basic health screening so that those with medical reasons such as an allergy to the medication being distributed, or taking a medication that might interact with the medication being distributed receive an alternative medication that is equally effective, but safer for that individual to take.
For those picking up medication for children, please remember to include their weight as this is important for the pharmacist in calculating the correct dosage for your child. Please fill out the form completely. Any questions that you might have, will be answered when you are seen at the distribution site.