CURRENT MEDICATION LIST

W Financial Services, Inc.

24201 W. Main Street, Plainfield, IL 60544 (708) 524-2791 phone
MEDICATION LIST

PLEASE PROVIDE AN UPDATED, ACCURATE AND COMPLETE LIST OF ALL MEDICATIONS YOU WOULD LIKE INCLUDED IN THE REVIEW.
*I understand that W Financial relies on the medication information I provide for my review, and that any medication misinformation can result in an inaccurate recommendation. By typing my name below, I acknowledge that the medication information I am providing is accurate and complete.
*Type your Name here*

First NameMiddle NameLast NameSuffix (Jr, Sr, III, ect)
Patient Birth Date*

MonthDayYear
Patient E-Mail*

Confirmation EmailConfirm E-mail
Patient Phone Number*

Area CodePhone Number
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a preferred pharmacy?
Please enter pharmacy here if you have a preference.
Patient Medications

Be sure to include all prescription medications. Over-the-counter, diabetic, dietary supplements and vitamins are not included in the review. If you do not take any Rx or do not have any to include in review, please check box below.
I DO NOT currently take any prescription medication which I would like included in a review:

No Rx at this time.

Please List All Medications

Patient Tobacco Usage
Tobacco Usage:*

Yes, I Smoke DailyYes, Sometimes I SmokeNo, I Quit SmokingNo, I Never Smoked
Date I Quit Smoking:*

MonthDayYear
# Cigarettes per day?*
Comments/Concerns:
Today's Date*

MonthDayYear
Type Security Code Below*
Please upload any files or documents you would like to add:

Browse Files

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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
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MEDICATION LIST