Legacy Health Insurance
641 Marketplace Drive #5
Waconia, MN 55387
info@LBCOnline.biz
TimTheMedicareMan.com
(952) 922-5677
Medication List
Please complete this form at least 24 hours before your scheduled meeting. If this form is not completed, your appointment may be rescheduled.
First Name
*
Last Name
*
Phone Number
*
Please enter a valid phone number.
Appointment Date (If Applicable)
-
Month
-
Day
Year
Date
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
Medication Name, Qty/Day & Dosage
Ex. Losartan, 1 Per Day, 100mg
If you'd prefer to upload a CURRENT medication list please upload the file below:
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Please include any notes below such as preferred pharmacy & primary care physician or clinic:
Ex: Marsden Pharmacy & Lakeview Clinic
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