N. Gonorrhea Treatment Order Form Search Submit Search Print this Page Home » For Professionals » Health Care & Dental Professionals » Communicable Disease Resources » Reportable Diseases Toolkit » Gonorrhea » N. Gonorrhea Treatment Order Form *Medications are to be used for N. Gonorrhea Treatment ONLY Health Care Professional (HCP) InformationHealth Care Professional's Name * Required First Last Health Centre/Family Health Team * Required Address * Required Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Email * Required Phone * RequiredGonorrhea First Line Treatment - Number of Treatment Kits Required * Required(Treatment Kits include; Ceftriaxone 0.25g vial, Lidocaine HCI 1% 0.9mL, Azithromycin 250mg tab x4)NotesHiddenHealth Unit Use OnlyHiddenCeftiaxone 0.25g vial - Lot NumberHiddenLidocaine HCI 1% 0.9mL - Lot NumberHiddenAzithromycin 250mg tab x4 - Lot NumberHiddenOrder filled by First Name Last Name HiddenDelivery/Pick-up Date YYYY slash MM slash DD HiddenHealth Unit Notes-CAPTCHA