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Check Your Eligibility in Less Than 2 Minutes

This quick form helps us verify your Medi-Cal coverage and confirm your free monthly wellness box. All information is securely processed in compliance with HIPAA standards.
Tell Us About Yourself
Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Date
Gender*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Where Should We Send Your Delivery?
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Do You Have Health Coverage That May Qualify You for This Program?
Type a question*

Yes, I have Medi-CalMaybe, I have a health planNo, I am uninsured
Your Medi-Cal ID (If Available)
Enter your Medi-Cal ID Number (if available):
Upload Your Medi-Cal ID (Optional)

If you have a picture of your Medi-Cal ID, you can upload it here for faster processing.
Cancelof
Would you like to notify your primary care physician that you are being prescribed these medications? If so, please leave their name and contact information.
Physician Name, Email or Telephone Number
Do you have any allergies or existing medical conditions we should be aware of?
Obesity, COPD, Diabetes, etc
Check all that apply to your current experience.
Body Discomfort: (Select all that apply)*

HeadacheBody achesFeverNone of the above
Nasal Discomfort: (Select all that apply)*

Reduced sense of smellSinus irritationRunny noseNone of the above
Respiratory Discomfort: (Select all that apply)*

Chest tightnessExcess mucusPersistent coughNone of the above
Do you have any allergies?
Do you have any existing medical conditions?
Additional Wellness Resources

As part of our program, you may also be eligible to receive a Health Box with essential wellness items. This box includes a selection of over-the-counter health products for general wellness and symptom relief.
What's Included:

✅ Up to (4) at-home health test kits

✅ Acetaminophen

✅ Bacitracin

✅ Vitamin D / Calcium

✅ Chest support supplement

✅ Ibuprofen

✅ Magnesium supplement

📌 No additional out-of-pocket cost for eligible participants.
I would like to add a Health Box

Yes
🚨 Important Notice

Before using any health or wellness products, consult a healthcare professional to ensure they are right for you. This program does not provide medical advice, diagnosis, or treatment. Always follow the guidance of a qualified healthcare provider regarding any health-related concerns.
Acknowledgment & Authorization

By signing below, I confirm that the information provided is accurate and that I am requesting eligibility review for home delivery of wellness products.
Signature*

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I agree to the Terms and Conditions. By signing this form, I consent to Stay Well US and its affiliated partners coordinating the delivery of eligible wellness products as requested.
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Check Your Eligibility in Less Than 2 Minutes

Tell Us About Yourself

Where Should We Send Your Delivery?

Do You Have Health Coverage That May Qualify You for This Program?

Check all that apply to your current experience.

Additional Wellness Resources

🚨 Important Notice

Acknowledgment & Authorization