SELF TEST AT HOME

Get 4 COVID-19 Tests Per Month Delivered at NO COST To You!

California Medicaid, California Residents: Pay $0

FILL OUT THIS FORM TO CONFIRM YOUR

ELIGIBILITY & CLAIM YOUR TEST NOW!

*You can cancel any time

Let’s Get You Started – It’s Quick & Secure

Step 1 of 4 – Takes Less Than 2 Minutes

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First Name

Last Name

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Email

Where Should We Send Your Tests?

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Medicaid ID Number (Optional):

Picture of Medicaid ID Card (Optional):

Last Step! Would You Like An Additional Wellness Kit?
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Additional Offer - NO COST:

We also offer our Health Box, which contains up to 7 OTC products completely covered by Medi-Cal. These products are: (4) OTC COVID Tests, Acetaminophen, Bacitracin, Vitamin D / Calcium, Chest Congestion Reliever, Vitamin C, Magnesium Supplement

(You will NEVER pay out of pocket for this service).

Yes, send me a No-Cost Health Box

Before taking any medications or over-the-counter drugs, consult a physician for a thorough evaluation. Always seek the advice of a physician or other qualified healthcare provider with any questions regarding a medical condition. Do not take medication if you have a known allergy to it.

Text me order updates & reminders. Msg & data rates may apply. Frequency varies. Reply HELP for help, STOP to cancel. Consent isn’t required for care.

Text me occasional wellness tips & offers. Msg & data rates may apply. Up to 4 msgs/mo. Reply HELP for help, STOP to cancel. Consent isn’t required for care.

I agree to Terms and Conditions. By signing this form, I am authorizing Stay Well US's Preferred Pharmacy to fill and ship my prescriptions.

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