Please check the items that you do not have access to during your home isolation. This is for a 14-day supply.*Please note that not all items are accessible. Items will be provided based on availability. Referring Physician Your address Phone number How many adults (18+) live in your home? How many children live in your home? NON-PERISHABLE FOOD ITEMS - None -Canned fruits Canned veggies Canned or powdered milk Broths Soups Stews Canned meat products or fish Beans Legumes Chickpeas Lentils Pastas Oatmeal Bread Buns Tortillas Cereals Peanut butter Jelly/jam Crackers Granola/cereal bars Bottled juice Frozen meals Bottled water Pedialyte/Gatorade MEDICATIONS - None -Antacids Cough & cold medications Pain relievers Vitamins HOUSEHOLD ITEMS - None -Toothpaste Body soap Shampoo Toilet paper Facial tissue Laundry detergent Bleach Distilled white vinegar Dishwasher detergent Dishwashing soap Alcohol-based hand sanitizer Fever thermometer Plastic trashbags Cleaning supplies Disposable gloves & masks ENTERTAINMENT ITEMS - None -Movies Board games Cards Crafts Special delivery instructions? Anything else we need to know? CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit Leave this field blank
