STD Drug Order Form

STD Drug Order Form

*This form is for Public Health Partners only.*

Your Name*

LPHA/Organization*

Street Address*

City*

State*

Zip*

Email*

Phone Number

Available Medications:

Azithromycin (250mg tablet, 30 tablets/bottle)

Quantity (bottles) Requested:

Bicillin (1.2mu/2ml syringe, 10 syringes/box) - a 2.4mu dose requires 2 syringes

Quantity (boxes) Requested:

Select

Ceftriaxone (500mg vial)

Quantity (vials) Requested:

Doxycycline (100mg tablet, 50 tablets/bottle)

Quantity (bottles) Requested:

Lidocaine (100mg/10ml or 200mg/20ml vial as available)

Quantity (vials) Requested:

Enter any comments or questions here:

Drugs provided by the Oregon STD Program fall under the state's MMCAP contract. Some LPHAs order medications independently under their individual 340B contracts. Any LPHA may order STD Program Bicillin for distribution to community clinics and providers.

Bicillin distribution: only STD Program Bicillin can be distributed to community providers. The federal 340B Drug Pricing Program prohibits diversion, which means that 340B drugs cannot be provided to ineligible patients. Keep STD Program Bicillin and 340B-priced Bicillin in separate inventories.

For more information on STD drug ordering and the Bicillin Access Program, visit our STD resources webpage.

For questions, contact:

OHA STD Program

prevention.info@odhsoha.oregon.gov

971-673-0153

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