Kansas Infertility Prevention Project Portal

KIPP Site Order Form

Bureau of Disease Control and Prevention
Sexually Transmitted Disease Program
1000 SW Jackson, Suite #210
Topeka, KS 66612-1274
Phone: (785) 296-5596                                          Fax: (785) 296-5590

* Denotes required fields.

* Facility Name:

* Address:

* City:

* Zip Code :

* Facility ID# :

* Contact Person:

* Phone Number:

Fax Number:

Email:

STD Medications:	Number Requested
Azythromycin 250mg tablets (single tablets)	Tablets
Azythromycin 250mg tablets, bottles of 30	Bottles
Doxycycline 100mg tablets (single tablets)	Tablets
Doxycycline 100mg capsules, bottles of 50	Bottles
Ceftriaxone (Rocephin) 250mg vial, 1ml per dose	Vials
Lidocaine 1%-10ml vial	Vials
Benzathine Penicillin G (Bicillin) Tubex, 1.2 million unit syringes	Syringes

Supplies:	Number Requested
Business Reply Envelopes
STD Awareness Wristbands
Gen-Probe Urine Specimen Collection Kits ***You will be billed $1.25 per kit***	Kits

Enter Notes Here

Questions: Please contact via email Stephanie Green or at (785) 296-5595.