Looking to Cut Back or Quit Nicotine?

Support doesn’t have to be all-or-nothing.
Check what options may be available to you in under a minute.

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First Name:

Last Name:

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Where Should We Send Your Quit Kit?

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Email:

Medicaid ID Number (Optional):

Picture of Medicaid ID Card (Optional):

If you don’t have this handy, that’s okay. We can still review your request

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Last Step! Authorization:
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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 acknowledge that I have had the opportunity to ask questions about smoking-cessation therapy, and my questions have been answered to my satisfaction.

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):

Text me order updates & reminders. Msg & data rates may apply. Frequency varies. Reply HELP for help, STOP to cancel. Consent isn’t required for care.

Text me occasional wellness tips & offers. Msg & data rates may apply. Up to 4 msgs/mo. Reply HELP for help, STOP to cancel. Consent isn’t required for care.

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This questionnaire is available in multiple languages upon request.
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