Gift Card Submission Request

First Name *

Last Name *

Date Of Birth *

Phone *

Address

Street Address *

City *

State *

Postal Code *

Apt / Unit #

Yes, contact me about my gift card. I agree to receive calls and texts from South Central Health Services (Cassiel LLC) at the number provided, including autodialed or prerecorded, to schedule my gift card delivery. Msg frequency varies. Msg & data rates may apply. Reply STOP to opt out, HELP for help. See Privacy Policy and Terms below.

I confirm the information provided is accurate and understand a valid phone number, home address, full name, and date of birth are required for delivery and eligibility verification.

A valid phone number is required to schedule the gift card delivery.
An accurate home address is required for delivery and to verify South Central Kentucky residency eligibility. Gift cards will only be delivered to the beneficiary’s listed home address.
A full legal name is required to identify the individual receiving the gift card.
Date of birth is required to confirm age eligibility.