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(1/6)
First Name:
Last Name:
Where Should We Send Your Quit Kit?
(2/6)
Email:
Medicaid ID Number (Optional):
Picture of Medicaid ID Card (Optional):
Tobacco Use History(This helps our pharmacist choose the right support for you)(3/6)
What tobacco products do you currently use? (Select all tobacco products you currently use.)
How many cigarettes do you smoke per day?
How many vapes per day?
How many cigars per day?
How many pipe uses per day?
How many sniffs per day?
How many dips per day?
If other nicotine product is used that is not listed above, please provide type and amount used per day.
How soon after waking do you have your first tobacco product?
How many years have you used tobacco regularly?
Have you tried to quit before?
Which NRT methods have you tried?
Did you experience side effects from nicotine replacement in the past?
If "other" side effect from nicotine replacement selected, please list below.
Which NRT method do you prefer?
Anything else you want the pharmacist to know?
Helping You Get the Right Care(Safety questions required before nicotine replacement therapy)(4/6)
Please indicate if you are currently taking any of the following medications
Please check any conditions that apply to you.
Any other medical conditions your pharmacist should be aware of?
Please provide a list of any allergies you have:
What symptoms do you experience when you do not use tobacco (and are not using nicotine replacement)?
Please List Any Other Symptoms:
Last Step! Authorization:(6/6)
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.
