Complete Your Request — It’s Quick & Secure
This short form is required to begin eligibility review, coverage review, and provider review. Provider review is required before any supplies can ship.
(1/5)
Are you 18 years of age or older?
Are you currently pregnant or trying to become pregnant?
Are you currently breastfeeding?
First Name:
Last Name:
Where Should We Send Your NRT Kit?
(2/5)
Email:
Medicaid ID Number (Optional):
Picture of Medicaid ID Card (Optional):
Tobacco Use History(This helps our pharmacist choose the right support for you)(3/5)
What tobacco products do you currently use? (Select all tobacco products you currently use.)
How many cigarettes do you smoke per day? Answer required for prescriber
How many vape puffs per day (how much nicotine is used)? Answer required for prescriber
How many cigars per day? Answer required for prescriber
How many pipe uses per day (how much nicotine is used)? Answer required for prescriber
How many snuffs per day (how much nicotine is used)? Answer required for prescriber
How many dips per day (how much nicotine is used)? Answer required for prescriber
Please list any other nicotine or tobacco products that you use that are not listed above and the amount used per day. Answer required for prescriber
How soon after waking do you have your first tobacco product?
How many years have you used tobacco regularly?
Do you experience any of the following symptoms when you do not use tobacco or nicotine? (Please check all that apply)
Please list any other symptoms you experience when you do not use tobacco or nicotine:
Have you tried to quit before?
Which NRT methods have you tried?
If "other" Nicotine Replacement Method has been used, please list method and amount below.
Did you experience side effects from nicotine replacement in the past?
If "other" side effect from nicotine replacement selected, please list below.
Anything else you want the pharmacist to know?
Helping You Get the Right Care(Safety questions required before nicotine replacement therapy)(4/5)
Please indicate if you are currently taking any of the following medications
Please list all medications and supplements that you are taking. Include name, dose, and number of times you take each item each day. If none, please type "none". Please list names of all medications you currently take or we will not be able to fulfill your request
In the PAST YEAR, have you had...
Select any medical conditions that apply to you or have ever applied to you:
Please list any additional medical conditions or reasons you take medications: if none, please type "none"
Please list any other medications and supplements that you haven't mentioned: If none, please type "none"
Select any of the following allergies that apply to you.
List any additional allergies and your reaction to exposure( i.e. medications, environmental, food, etc.) If none, please type "none".
What is your typical blood pressure reading (single answer)?
When was your last known or suspected exposure to Covid - 19?
Last Step! Authorization:(5/5)
Warning: 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.
I agree to Terms and Conditions. By signing this form, I authorize Stay Well US's Preferred Pharmacy to submit a claim, fill, and ship my no cost nicotine replacement therapy (NRT) kit.
SMS Consent Options (required by A2P 10DLC):
This questionnaire is available in multiple languages upon request.¿Necesita el formulario en español? Pídaselo al farmacéutico.هل تحتاج النموذج باللغة العربية؟ اطلبه من الصيدلي.
