Dr. and Prescriptions List
Please complete all of these sections to the best of your ability. This will help us be more prepared for our meeting. If you have any questions, or complications - please give us a call at (828) 884-8080.
What line of business do you currently have with Dalton Insurance? Please select all that apply.
** Please note - due to industry changes, we will no longer be able to service standalone PDP's.**
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Medicare Advantage Plan
Medicare Supplement
Standalone PDP
Client Details
Full Name
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First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from physical)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your Date Of Birth?
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What is your Medicare ID#? Include Part A & B dates as well.
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Who is your Primary Care Physician? (Name and Practice Name)
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What pharmacy do you use?
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What prescriptions do you take? (If none, put "none" in the first box)
Rows
RX name:(EX: Novolog)
Dosage:
(EX: 25mg)
How many daily?
Refill frequency?(EX: 30, 90 days)
1.
2
3.
4.
5.
6.
7.
8.
9.
10.
If you need more space for your prescription list, please use this box:
What Specialists do you see? (Cardiologist, Dermatologist, Neurologist, etc.)
Rows
Doctor Name
1.
2.
3.
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5.
Do you give us permission to contact you?
*
Please Select
Yes
No
What is your preferred method of contact?
*
Please Select
Phone Call
Text
Email
Please select what you are interested in discussing with us:
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Medicare Advantage Plans (Part C) and Cost Plans
Stand-Alone Medicare Prescription Drug Plans (Part D)
Medicare Supplement (Medigap) Plans
Dental-Vision-Hearing Products
Hospital Indemnity Plans
All Of The Above (Select this one)
Please sign here:
Continue
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