Health Box Request Form

Protect Your Family. Protect your Community

Medi-Cal Patients: Get your No-Cost Health Box Today!

FILL OUT THE FORM TO CONFIRM YOUR

ELIGIBILITY & CLAIM YOUR HEALTH BOX NOW.

YOU MAY REQUEST A HEALTH BOX EACH MONTH.

Health Box Request Form

First Name *

Last Name *

Gender *

Female

Male

Prefer Not To Say

Date of birth *

Email *

Phone *

City *

State *

Postal code *

Address *

Medicaid ID Number (Optional):

Picture of Medicaid ID Card (Optional):

Check the symptoms that you' re currently experiencing *

Headache

Fever

Body Aches

None

For MEDI-CAL Patients: We offer our Health Box, which contains 8 OTC prodcuts completely covered by Medi-Cal. Would you like to receive a Heath Box containing the following products: Acetaminophen, Bacitracin, Vitamin D / Calcium, Chest Congestion Reliver, Ibuprofen, Anti-acid (Lansoprazole), (8) OTC COVID Tests, and Narcan? (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.

Signature

Clear

Last four of SSN *

I agree to Terms and Conditions. By signing this form, I am authorizing Stay Well US's Preferred Pharmacy to fill and ship my prescription each of the (8) OTC products in the Health Box:

- ACETAMINOPHEN 500 MG CAPLET

- GUAIFENESIN 400 MG (Check Congestion Relief)
- RISACAL-D TABLET (Calcium / Vit D)

- IBUPROFEN 200 MG SOFTGEL

- BACITRACIN 500 UNIT/GM OINTMENT

- (8) RAPID OTC COVID TESTS

- LANSOPRAZOLE DR 15 MG CAPSULE

- NARCAN 4 MG NASAL SPRAY

I understand I have the right and ability to consult with the pharmacist regarding these prescriptions, and I have been given the opportunity to do so.

I understand I have an obligation to consult with my medical provider before taking any medication or supplement.