STI Treatment Kits Order Sheet
Prescription Template
400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739
Patient
SexMF
Treatment Kits
Check one per indication
Pre-assembled treatment kits aligned with Manitoba STI protocols. Kits supplied through the provincial program where applicable; the pharmacy confirms current stock and program eligibility on receipt.
Gonorrhea
Cefixime 400 mg (2 tabs)
Ceftriaxone 250 mg / lidocaine 1% IM kit
Azithromycin 250 mg (4 tabs)
Azithromycin 250 mg (8 tabs)
Chlamydia
Azithromycin 250 mg (4 tabs)
Doxycycline 100 mg (14 caps)
Amoxicillin 500 mg (21 caps) — pregnancy
LGV / Chancroid
Doxycycline 100 mg (42 caps) — LGV
Ceftriaxone 250 mg / lidocaine 1% IM kit — chancroid
Syphilis
Bicillin LA 1.2 MU/2 mL — 2 syringes / 1 treatment
Bicillin LA 1.2 MU/2 mL — 6 syringes / 3 weekly treatments
Doxycycline 100 mg (28 caps)
Doxycycline 100 mg (56 caps)
Pelvic Inflammatory Disease
Ceftriaxone 250 mg / lidocaine 1% IM kit
Doxycycline 100 mg (28 caps)
Metronidazole 250 mg (56 tabs)
Azithromycin 250 mg (7 tabs)
Other
Other:
Directions / Notes
Sig / notes
Patient counselling sheet available at tachepharmacy.com/instructions/sti-treatment and dispensed with each kit on request.
Deliver to clinic
yes
patient pickup
Date needed
Prescriber
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Signature