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Order Form

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Team Name *

Main Contact Name *

Shipping Address *

League Affiliation *

Contact Phone *

Contact Email *

Azithromycin Pack (Z-Pak) *

Azithromycin Pack Quantity / Instructions *

Celebrex *

Celebrex Quantity / Instructions *

Celecoxib (generic Celebrex) *

Celecoxib Quantity / Instructions *

Celestone *

Celestone Quantity / Instructions *

Cephalexin (generic Keflex) *

Cephalexin Quantity / Instructions *

Cyclobenzaprine (generic Flexeril) *

Cyclobenzaprine Quantity / Instructions *

Depo Medrol Injection 40mg/ml vial *

Depo Medrol Injection Quantity / Instructions *

Dexamethasone 4mg/ml vial *

Dexamethasone Quantity / Instructions *

Diclofenac ER (generic Voltaren XR) *

Diclofenac ER Quantity / Instructions *

Diclofenac DR (generic Voltaren EC) *

Diclofenac DR Quantity / Instructions *

Epipen *

Epipen Quantity / Instructions *

Flector *

Flector Quantity / Instructions *

Indomethacin ER *

Indomethacin ER Quantity / Instructions *

Kenalog 40 mg/ml vial *

Kenalog Quantity / Instructions *

Ketorolac vial *

Ketorolac Quantity / Instructions *

Lidocaine vial *

Lidocaine Quantity / Instructions *

Marcaine vial *

Marcaine Quantity / Instructions *

Methylprednisolone (generic Medrol) *

Methylprednisolone Quantity / Instructions *

Naproxen (generic Naprosyn) *

Naproxen Quantity / Instructions *

Prednisone *

Prednisone Quantity / Instructions *

Proair HFA Inhaler *

Proair HFA Inhaler Quantity / Instructions *

Sulfamethoxazole Trimethoprim (generic Bactrim) *

Sulfamethoxazole Trimethoprim Quantity/Instructions *

Ventolin HFA Inhaler *

Ventolin HFA Inhaler Quantity / Instructions *

Xylocaine vial *

Xylocaine Quantity / Instructions *

Other Items Not Listed (Please Include Details) *

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