New Jersey Department of Health MEDICATION STD Program REQUEST PO Box 363 Trenton, NJ Agency Name Reporting Period Shipping Address From: City State Zip Code To: AMOUNT REQUESTED EXPIRED, BEGINNING AMOUNT ENDING AMOUNT MEDICATION LOST, OR DISPENSING INVENTORY DISPENSED INVENTORY SHIPPED QUANTITY DESTROYED UNIT Azithromycin (250 mg) Bottle(s) 250 mg / 30 per bottle Azithromycin (500 mg) Bottle(s) 500 mg / 30 pills per bottle Aldara Cream (Imiquimod) Tube(s) .25 mg Tube / 12 tubes per box Box(es) Bicillin LA (Benzathine-Penicillin) Box(es) 1,200,000 uI/4 ml / 10 syringes per box Unit(s) Bicillin LA (Benzathine-Penicillin) Box(es) 2,400,000 uI/4 ml / 10 syringes per box Unit(s) Bactrim (Sulamethaxazol/Trimethoprim) Bottle(s) 800 mg Sulam, 160 mg Trim / 100 per bottle Doxycycline Bottle(s) 100 mgl / 50 per bottle Elimite/Acticin Cream 5%(Permetherin) Tube(s) 60 gram / 24 tubes per case) Box(es) Bottle(s) Erythromycin (Ery-Tab) 250 mg / 30 per bottle (of 30) Erythromycin (Ery-Tab) Bottle(s) (of 100) 250 mg / 100 per bottle Lidocaine w/preservative (multi dose) Unit(s) 50 ml / 25 units per box Box(es) Metronidazole (Flagyl) Bottle(s) 250 mg / 100 per bottle Rocephin (Ceftriaxone) Unit(s) Box(es) 250 mg / 6 cc / 10 per box Sterile Water Unit(s) 10 ml / 10 cc / 25 units per box Box(es) Terconazole (Terazol) Unit(s) 0.71 oz., 20 gram / Single Units Diflucan (Fluconazole) Bottle(s) 200 mg / 30 per bottle Requested By (Print) Signature Phone Date Approved to Ship Approved Date Order No. Shipped By Date Shipped FOR STATE USE ONLY Notes:
New Jersey Department of Health STD Program PO Box 363 Trenton, NJ MEDICATION REQUEST Agency Name Reporting Period Shipping Address From: City State Zip Code To: MEDICATION BEGINNING INVENTORY AMOUNT DISPENSED EXPIRED, LOST, OR DESTROYED ENDING INVENTORY AMOUNT REQUESTED AMOUNT SHIPPED QUANTITY DISPENSING UNIT Azithromycin (250 mg) 250 mg / 30 per bottle Bottle(s) Azithromycin (500 mg) 500 mg / 30 pills per bottle Bottle(s) Aldara Cream (Imiquimod) .25 mg Tube / 12 tubes per box Tube(s) Box(es) Bicillin LA (Benzathine-Penicillin) 1,200,000 uI/4 ml / 10 syringes per box Box(es) Unit(s) Bicillin LA (Benzathine-Penicillin) 2,400,000 uI/4 ml / 10 syringes per box Box(es) Unit(s) Bactrim (Sulamethaxazol/Trimethoprim) 800 mg Sulam, 160 mg Trim / 100 per bottle Bottle(s) Doxycycline 100 mgl / 50 per bottle Bottle(s) Elimite/Acticin Cream 5%(Permetherin) 60 gram / 24 tubes per case) Tube(s) Box(es) Erythromycin (Ery-Tab) 250 mg / 30 per bottle Bottle(s) (of 30) Erythromycin (Ery-Tab) 250 mg / 100 per bottle Bottle(s) (of 100) Lidocaine w/preservative (multi dose) 50 ml / 25 units per box Unit(s) Box(es) Metronidazole (Flagyl) 250 mg / 100 per bottle Bottle(s) Rocephin (Ceftriaxone) 250 mg / 6 cc / 10 per box Unit(s) Box(es) Sterile Water 10 ml / 10 cc / 25 units per box Unit(s) Box(es) Terconazole (Terazol) 0.71 oz., 20 gram / Single Units Unit(s) Diflucan (Fluconazole) 200 mg / 30 per bottle Bottle(s) Requested By (Print) Signature Phone Date FOR STATE USE ONLY Approved to Ship Approved Date Order No. Shipped By Date Shipped Notes:
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