Prescription Form

Prescription Drug Intake Form
Name*

First NameLast Name
Current Plan Name*
Date of Appointment (if no appt yet, say none)*
What best describes the reason for reviewing your prescription list?*
Prescription drug name, dosage, quantity, type (tablet, capsule, insulin, etc) - please include name of prescription including ER, SR, XL, etc.*
List 1-3 preferred pharmacies where you are willing to go to if the price is lower.
Pharmacy #1
Pharmacy #2
Pharmacy #3
Is there anything else I should know?
Please verify that you are human*
Any pricing information we provide is based on estimates using current prescription drug pricing and drug plan information currently available. Any of this information can change due to plan changes or drug pricing available.
Should be Empty:

Prescription Drug Intake Form