This kit was designed at the request of Chris White, ND by Granite Pharmacy, Missoula – 2230 27th Ave Ste 2 Missoula, MT 59804-5130 Tel:(406) 926-2940. You can order these kits from Granite or you can copy this form for your preferred pharmacy. The cost will vary by pharmacy some, but it is extraordinarily affordable. It’s also true that this kit is not as easy to use as the pre-loaded, auto-inject devices. You will want to choose and instruct the patients you offer this option to accordingly

 1. Epinephrine 1 mg/mL ampule (NDC: 54288-0103-10) count #3 mL + _____ refills

Sig: inject 0.3 mL (0.3 mg) IM into thigh PRN anaphylactic allergic reaction, call 911. If anaphylactic symptoms persist, may repeat in 5 to 15 minutes as needed. (1 ampule for training; 2 ampules for administration)

2. BD 1 mL Insulin syringe, 25G, 1 inch (NDC: 08290-3296-22) count #3 +_____ refills

Sig: Use as directed (1 syringe for training; 2 syringes for administration of epinephrine)

3. BD filter needle, 19G, 1 1/2 inch (NDC: 08290-3052-00) count #3 + _____ refills 

Sig: Use as directed (1 needle for training, 2 for use with epinephrine)

4. Alcohol prep pad (NDC: 37205-0155-78) or Sterile Gauze Pad (NDC: 09629-5102-86) count #3 + ______ refills (Provider please circle one) Sig: Use as directed (1 for training; 2 for use with epinephrine