AUVI-Q® Educational Institution Order Form

Initiate the AUVI-Q order for your educational institution by completing the form below. HealthFirst will respond with your pricing and answer any questions you may have. If you need assistance please call Ashley at 325-734-5886.

Authorized Requestor Name:*
Contact Email*
Contact Phone*
First and Last Name of Doctor*
First Last
State License #*
Customer # (If known)
Name of Educational Institution*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Shipping Address (If different than above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Payment Method:
- Credit Card
- Purchase Order
Payment information will be collected via phone during the order confirmation process.
Cartons of AUVI-Q 0.1 mg:*
For patients weighing 16.5-33 lb. Please indicate the total number of cartons requested for each dose. Each carton contains 2 auto-injectors and 1 trainer.
Cartons of AUVI-Q 0.15 mg:*
For patients weighing 33-66 lb. Please indicate the total number of cartons requested for each dose. Each carton contains 2 auto-injectors and 1 trainer.
Cartons of AUVI-Q 0.3 mg:*
For patients weighing over 66 lb. Please indicate the total number of cartons requested for each dose. Each carton contains 2 auto-injectors and 1 trainer.
Additional Notes/Comments:
Consent:*
I agree
Purchaser agrees to HealthFirst’s Terms and Conditions and further acknowledges that the product should be used only after consultation with a physician and in accordance with the supplied Instructions for Use and any applicable local or state regulations.

For children weighing
16.5lbs to 33 lbs.

For children weighing
33 lbs to 66 lbs.

For anyone who
weighs 66 lbs or more.

AUVI-Q® Educational Institution Order Form

For children weighing16.5lbs to 33 lbs.

For children weighing33 lbs to 66 lbs.

For anyone whoweighs 66 lbs or more.

AUVI-Q® Educational Institution Order Form

For children weighing
16.5lbs to 33 lbs.

For children weighing
33 lbs to 66 lbs.

For anyone who
weighs 66 lbs or more.