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Practice Name*
Contact Name*
Medical Specialty*
Customer # (if applicable)
Email Address*
Phone Number*
Phone Ext.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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Name
StrengthSize
Pharma, 2 Gallon Pharmaceutical Recovery (1 included in program)
25grams120mL
ACTIVATED CHARCOAL TUBE- ACTIDOSE-AQUA 25grams
25grams120mL
ADENOSINE INJECTION, USP 60mg/20mL (3mg/mL) 20mL VIAL
3mg/mL20mL
ADENOSINE INJECTION, USP 6mg/2mL (3mg/mL) VIAL
6mg/2mL (3mg/mL)2mL
ALBUTEROL SULFATE - PROAIR HFA 90mcg
90mcg8.5gr
ALBUTEROL SULFATE - VENTOLIN HFA 90mcg
90mcg8gm
AMINOPHYLLINE INJ., USP 500mg (25mg/mL)
25mg/mL20mL
AMINOPHYLLINE INJECTION, USP 250mg (25mg/mL) 10mL VIAL
250mg (25mg/mL)10mL
AMIODARONE HYDROCHLORIDE INJECTION 150mg/3mL (50mg/mL) VIAL
150mg/3mL (50mg/mL)3mL
AMMONIA INHALANT 0.3mL
0.3mL
ASPIRIN TABLETS (CHEWABLE) LOW DOSE 81mg 90 PER BOTTLE
81mg90 TAB
ASPIRIN TABLETS 325mg 100 PER BOTTLE
325mg100 TAB
ATROPINE SULFATE INJECTION, USP 0.4mg/mL 1mL VIAL
0.4mg/mL1mL
ATROPINE SULFATE INJECTION, USP 0.5mg (0.1 mg/mL) SYR
0.5mg (0.1 mg/mL)5mL
ATROPINE SULFATE INJECTION, USP 1mg (0.1mg/mL) SYR
1mg (0.1mg/mL)10mL
ATROPINE SULFATE INJECTION, USP 8mg/20mL (0.4mg/mL) 20mL VIAL
8mg/20mL (0.4mg/mL)20mL
BACTERIOSTATIC 0.9% SODIUM CHLORIDE INJECTION, USP 10mL VIAL
0.9% 10mL10mL
BACTERIOSTATIC 0.9% SODIUM CHLORIDE INJECTION, USP 30mL VIAL
0.9% 30mL30mL
CALCIUM CHLORIDE INJECTION 10%, USP 1gram (100mg/mL) SYR
1gram (100mg/mL)10mL
CALCIUM GLUCONATE INJECTION, USP 10% (100mg/mL) 10mL VIAL
100mg/mL10mL
CALCIUM GLUCONATE INJECTION, USP 10% (100mg/mL) 50mL VIAL
100mg/mL50mL
CLONIDINE HCl INJECTION 1000mcg/10mL (100mcg/mL) 10mL VIAL
100mcg/mL10mL
CLONIDINE HYDROCHLORIDE 0.1mg. USP, ONE TABLET
0.1mg1 tablet
CLORAPREP SINGLE SWABSTICK 1.75mL
1.75mLSwabstick
DEXAMETHASONE SODIUM PHOSPHATE INJECTION, USP 10mg/mL 2mL VIAL
10mg/mL2mL
DEXAMETHASONE SODIUM PHOSPHATE INJECTION, USP 20mg/5mL (4mg/mL) VIAL
20mg/5mL (4mg/mL)5mL
DEXTROSE INJECTION 5%, USP 100mL BAG
5% DEXTROSE PER 100mL100mL
DEXTROSE INJECTION 5%, USP 250mL BAG
5%250mL
DEXTROSE INJECTION 5%, USP 500mL BAG
5%500mL
DEXTROSE INJECTION 50%, USP 25grams (0.5g/mL) 50mL SYR
25grams (0.5g/mL)50mL
DEXTROSE INJECTION 50%, USP 25grams/50mL (0.5g/mL) VIAL
25grams/50mL (0.5g/mL)50mL
DEXTROSE INJECTION, INFANT 25% USP 2.5g (250mg/mL) ANSYR SYR
2.5g (250mg/mL)10mL
DIGOXIN INJECTION, USP 500mcg/2mL 0.5/2mL (250mcg/mL) AMP
500mcg/2mL 0.5/2mL (250mcg/mL)2mL
DILTIAZEM (Cardizem) HYDROCHLORIDE INJECTION 25mg/5mL (5 mg/mL) 5mL VIAL
25mg/5mL (5 mg/mL5mL
DIPHENHYDRAMINE HCl 25mg ONE CAPSULE
25mg1 capsule
DIPHENHYDRAMINE HCl INJECTION, USP 50mg/mL 1mL CARP
50mg/mL1mL
DIPHENHYDRAMINE HCl INJECTION, USP 50mg/mL 1mL VIAL
50mg/mL1mL
DOBUTAMINE IN 5% DEXTROSE INJECTION, USP 500mg 250mL BAG
500mg250mL
DOBUTAMINE INJECTION, USP 250mg PER 20mL VIAL
250mg PER 20mL20mL
DOPAMINE HCl INJECTION, USP 200mg (40 mg/mL) 5mL VIAL
200mg (40 mg/mL)5mL
DOPAMINE HCl INJECTION, USP 400mg (40mg/mL) 10mL VIAL
400mg (40mg/mL)10mL
DOPAMINE HYDROCHLORIDE IN 5% DEXTROSE INJECTION, USP 400mg 250mL BAG
400mg250mL
EPHEDRINE SULFATE INJECTION, USP 50 mg/mL 1mL VIAL
50 mg/mL1mL
EPINEPHRINE AUTO INJECTOR 0.15mg - IMPAX
0.15mg2mL
EPINEPHRINE AUTO INJECTOR 0.30mg - IMPAX
0.30mg2mL
EPINEPHRINE AUTO INJECTOR USP 0.15mg -BRAND: AUVI-Q
.15mg0.76mL
EPINEPHRINE AUTO INJECTOR USP 0.30mg -BRAND: AUVI-Q
.3mg0.76mL
EPINEPHRINE INJECTION 1:1000 - ADRENALIN 1mg/mL 1:1000 1mL VIAL
1mg/mL 1:10001mL
EPINEPHRINE INJECTION 1:1000 - ADRENALIN 1mg/mL 1:1000 30mL VIAL
1mg/mL 1:100030mL
EPINEPHRINE INJECTION, USP 1mg/10mL (0.1mg/mL) SYR (1:10,000)
1mg/10mL (0.1mg/mL)10mL
ESMOLOL (Brevibloc) HYDROCHLORIDE INJECTION 100mg per10mL VIAL
10mg/1mL10mL
ESMOLOL HYDROCHLORIDE INJECTION 100mg per10mL VIAL
10mg/1mL10mL
FLUMAZENIL INJECTION, USP 0.5mg/5mL (0.1mg/mL) VIAL
0.5mg/5mL (0.1mg/mL)5mL
FLUMAZENIL INJECTION, USP 1mg/10mL (0.1 mg/mL) VIAL
1mg/10mL (0.1 mg/mL)10mL
FUROSEMIDE INJ., USP 20mg/2mL (10mg/mL) VIAL
20mg/2mL (10mg/mL)2mL
FUROSEMIDE INJECTION, USP 100mg (10mg/mL) 10mL VIAL
100mg (10mg/mL)10mL
FUROSEMIDE INJECTION, USP 40mg/4mL (10 mg/mL) 4mL VIAL
10mg/mL4mL
GLUCAGON - GLUCAGEN (rDNA ORGIN) FOR INJECTION} 1mg PER KIT
1mg1mL
GLUCOSE - INSTA-GLUCOSE
31g1.09oz
GLYCOPYRROLATE INJECTION, USP 0.2mg/mL 1mL VIAL
0.2mg/mL1mL
HETASTARCH 6% IN 0.9% SODIUM CHLORIDE INJECTION 500mL BAG
6% and 0.9%500mL
HYDRALAZINE HYDROCHLORIDE INJECTION, USP 20mg/mL 1mL VIAL
20mg/mL1mL
IBUPROFEN ORAL SUSPENSION- CHILDREN'S 100mg PER 5mL
100mg5mL
INTRALIPID 20% 250mL BAG
20%250mL
KETOROLAC TROMETHAMIN 30mg/mL 1mL VIAL
30mg/mL1mL
KETOROLAC TROMETHAMIN 60mg/2mL VIAL
60mg/2mL2mL
LABETALOL HYDROCHLORIDE INJECTION, USP 100mg/20mL (5mg/mL) VIAL
100mg/20mL (5mg/mL)20mL
LACTATED RINGER'S AND 5% DEXTROSE INJECTION, USP 1000mL BAG
600mg/100mL1000mL
LACTATED RINGER'S INJECTION, USP 1000mL BAG
1000mL
LACTATED RINGER'S INJECTION, USP 500mL BAG
500mL
LIDOCAINE HCl 1% AND EPINEPHRINE 1:100,000 INJECTION, USP 20mL VIAL
1% and 1:100,00020mL
LIDOCAINE HCl AND 5% DEXTROSE INJECTION USP 2g (4mg/mL) 500mL BAG
2g (4mg/mL)500mL
LIDOCAINE HCl INJECTION 1% USP 50mg/5mL SYR
50mg/5mL5mL
LIDOCAINE HCl INJECTION 2%, USP 1000mg/50mL (20mg/mL) 50mL VIAL
1000mg/50mL (20mg/mL)50mL
LIDOCAINE HCl INJECTION 2%, USP 100mg/5mL (20mg/mL) VIAL
100mg/5mL (20mg/mL)5mL
LIDOCAINE HCl INJECTION 2%, USP 100mg/5mL SYR
100mg/5mL5mL
MAGNESIUM SULFATE INJECTION 50%, USP 5grams/10mL ANSYR SYR
5grams/10mL10mL
MAGNESIUM SULFATE INJECTION, USP 50% 10g/20mL (0.5g/mL) 20mL VIAL
0.5g/mL20mL
METOCLOPRAMIDE INJ., USP 10mg/2mL (5mg/mL) VIAL
10mg/2mL (5mg/mL)2mL
METOPROLOL (Lopressor) TARTRATE INJECTION, USP 5mg/5mL (1mg per mL) Vial
5mg/5mL (1mg per mL)5mL
NALBUPHINE HCI INJECTION 10mg/mL 10mL VIAL
10mg/mL10mL
NALBUPHINE HCI INJECTION 20mg/mL 10mL VIAL
20mg/mL10mL
NALOXONE HCl - NARCAN NASAL SPRAY 4mg/.1mL 2-PACK
4mg/.1mL0.1mL 2pack
NALOXONE HCl INJECTION, USP (1mg/mL) 2mL SYR
1mg/mL2mL
NALOXONE HCl INJECTION, USP 0.4mg/mL 1mL CARP
0.4mg/mL1mL
NALOXONE HCl INJECTION, USP 0.4mg/mL 1mL VIAL
0.4mg/mL1mL
NEOSTIGMINE METHYLSULFATE INJECTION, USP 10mg/10mL (1mg/mL) 10mL VIAL
1mg/mL10mL
NITROGLYCERIN - NTG PASTE 2% TUBE
2%30gm TUBE
NITROGLYCERIN IN 5% DEXTROSE INJECTION 50mg PER 250mL VIAL
50mg PER 250mL250mL
NITROGLYCERIN LINGUAL SPRAY 400mcg PER SPRAY 60 METERED SPRAYS
400mcg per spray4.9g
NITROGLYCERIN SUBLINGUAL TABLETS, USP 0.4mg/TABLET 25TABS
0.4mg/tablets25 tablets
ONDANSETRON INJECTION, USP 4mg/2mL (2mg/mL) VIAL
4mg/2mL (2mg/mL)2mL
ONDANSETRON ORALLY DISINTEGRATING TABLET USP 4mg
4mg1 tablet
PHENYLEPHRINE HCl INJECTION, USP 10mg/mL 1mL VIAL
10mg/mL1mL
PHENYTOIN (Dilantin) SODIUM INJ., USP 100mg/2mL (50mg/mL) VIAL
100mg/2mL (50mg/mL)2mL
PHENYTOIN (Dilantin) SODIUM INJ., USP 250mg/5mL (50mg/mL) VIAL
250mg/5mL (50mg/mL)5mL
PROCAINAMIDE HCl INJECTION, USP 1gram/10mL TOTAL (100mg/mL) 10mL VIAL
1gram/10mL TOTAL (100mg/mL)10mL
PROMETHAZINE HCl INJECTION, USP 25mg/mL 1mL VIAL
25mg/mL1mL
PROMETHAZINE HCl INJECTION, USP 50mg/mL 1mL AMPULE
50mg/mL1mL
PROPOFOL INJECTION EMULSION 200mg/20mL (10mg/mL) VIAL
200mg/20mL (10mg/mL)20mL
PROPRANOLOL HYDROCHLORIDE INJECTION, USP 1mg/mL 1mL VIAL
1mg/mL1mL
RANITIDINE TABLETS, USP 75mg ACID REDUCER 30 TABS
30 Tablets75mg
ROCURONIUM BROMIDE INJ. 100mg/10mL (10mg/mL) 10mL VIAL
10mg/mL10mL
ROCURONIUM BROMIDE INJ. 50mg/5mL (10mg/mL) 5mL VIAL
10mg/mL5mL
SODIUM BICARBONATE 4% (2.4%mEq) ADDITIVE SOLUTION 5mL
4% - ADDITIVE SOLUTION5mL
SODIUM BICARBONATE INJ, 4.2% INFANT 5mEq (0.5 mEq/mL) 10mL SYR
0.5 mEq/mL10mL
SODIUM BICARBONATE INJ. 8.4%, USP 50mEq (1mEq/mL) 50mL SYR
50mEq (1mEq/mL)50mL
SODIUM BICARBONATE INJ. 8.4%, USP 50mEq (1mEq/mL) 50mL VIAL
50mEq (1mEq/mL)50mL
SODIUM CHLORIDE INJECTION 0.9%, USP 1000mL BAG
0.9% PER 1000mL1000mL
SODIUM CHLORIDE INJECTION 0.9%, USP 100mL BAG
0.9% PER 100mL100mL
SODIUM CHLORIDE INJECTION 0.9%, USP 10mL SYR
0.90%10mL
SODIUM CHLORIDE INJECTION 0.9%, USP 10mL VIAL
0.90%10mL
SODIUM CHLORIDE INJECTION 0.9%, USP 250mL BAG
0.9% 250mL250mL
SODIUM CHLORIDE INJECTION 0.9%, USP 500mL BAG
0.9% 500mL500mL
SOLU-CORTEF 100mg 2mL ACT-O-VIAL
100mg2mL
SOLU-CORTEF 250mg 2mL ACT-O-VIAL
250mg2mL
SOLU-MEDROL 125MG PER VIAL 2mL ACT-O-VIAL
125mg2mL
SOLU-MEDROL 40MG PER VIAL 1mL ACT-O-VIAL
40mg1mL
STERILE WATER FOR INJECTION, USP 100mL VIAL
100mL
STERILE WATER FOR INJECTION, USP 10mL VIAL
10mL
STERILE WATER FOR INJECTION, USP 50mL VIAL
50mL
SUCCINYLCHOLINE CHLORIDE INJECTION, USP 200mg (20mg/mL) 10mL VIAL
20mg/mL10mL
VASOPRESSIN INJECTION - VASOSTRICT 20 UNITS PER mL 1mL VIAL
20 UNITS PER mL1mL
VERAPAMIL HCl INJECTION, USP 10mg (2.5 mg/mL) 4mL ANSYR SYR
10mg (2.5 mg/mL)4mL
VERAPAMIL HCl INJECTION, USP 5mg/2mL (2.5 mg/mL) VIAL
5mg/2mL (2.5 mg/mL)2mL
Additional Medications Needed
Medication Name
Strength
Size
Manufacturer NDC#
Qty.
Row 2 Name
Row 2 Strength
Row 2 Size
Row 2 NDC#
Row 2 Qty.
Row 3 Name
Row 3 Strength
Row 3 Size
Row 3 NDC#
Row 3 Qty.
Row 4 Name
Row 4 Strength
Row 4 Size
Row 4 NDC#
Row 4 Qty.

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