Healthy Baby Program
Please complete this survey to request diapers and/or OTC products for children enrolled in the Gibbs Pharmacy Healthy Baby Program. Eligible children under the age of 2 and on TennCare are able to receive up to 100 diapers per month through their TennCare pharmacy benefit.
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Child's Name
*
First Name
Last Name
Child's Date of Birth
*
Child's Gender
*
Please Select
Male
Female
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Pediatrician Name (First and Last)
Child's TN Optum ID (or mothers ID Number if child has not yet been assigned one.)
Picture of Child's Insurance Cards
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Child Weight (pounds)
*
Child Height (inches)
*
Does the child have any allergies?
*
Yes
No
Unknown
If the child has allergies, please list them below.
If the child takes any medication currently, please list them below.
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
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Cuties Brand Diaper Size (Note we can attempt to order other diaper brands, but cannot guarantee availability, please indicate preferred brand and size in "other" field")
Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
Size 6
Size 7
Other
One Month Supply (100 diapers) or Two Month Supply (200 Diapers)
One Month (100 diapers)
Two month (200 diapers)
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Over The Counter Items
The parent or guardian may request these products once every month (30 day period). These items will be billed to the child's TennCare prescription insurance and should have little to no copay. These medications are not intended to replace a provider visit or consultation with a licensed medical provider. They are simply over the counter medications already available, but the pharmacist will provide their expertise, counseling, and education to improve patient care with these products.
Allergies (eligible for 1 full package):
Zyrtec (Cetirizine) 5mg/ml Liquid
Saline 0.65% Nasal Spray
Laxative Agents (eligible for 1 full package):
Glycerin Pediatric Suppositories
Topical Anti-Infective Agents (eligible for 1 full package)
Bacitracin 500 u/g cream
Neosporin (Triple Antibiotic Ointment)
Analgesics (Pain/Fever/etc)
Tylenol (Acetaminophen) 160mg/5ml Liquid
Motrin (Ibuprofen) 100mg/5ml Liquid (not recommended for children <6 months old)
Tylenol (Acetaminophen) 80mg Suppositories
Multivitamin
Poly-Vi-Sol (Multivitamin Liquid)
Poly-Vi-Sol + Iron (Multivitamin Liquid)
Chewable Vitamins
D-Vi-Sol (Vitamin D Liquid)
Multivitamin
Poly-Vi-Sol (Multivitamin Liquid)
Poly-Vi-Sol + Iron Multivitamin Liquid
Chewable Vitamins
D-Vi-Sol (Vitamin D) Liquid
Complementary/Alternative Medications
Aerochamber
Diaper Rash Cream
Happy Hiney Diaper Rash Cream
How did you hear about our program?
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