DO NOT USE - Clone of Medicare Consultation Intake Form

Are You Enrolled in Medicare?*

NoYes
Medicare ID Number (if already enrolled in Medicare)
Medicare Part A Effective Date (check your Medicare card)

MonthDayYear
Date
Medicare Part B Effective Date (if enrolled - check your Medicare card)

MonthDayYear
Date

	First Name	Last Name	City/Town
PCP

	First Name	Last Name	City/Town
PCP

“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.”

CONSENT
You hereby understand and agree that by using this Web Site, you automatically and without any further action have established a business relationship between you and Savvy Medicare Strategies. As a result you agree to allow Savvy Medicare Strategies to contact you about its business via telephone, e-mail and /or standard mail using the contact information you have provided. You hereby consent to such contact even if your phone number is on any Do Not Call list.
Should be Empty:

	Prescription Name (brand required?)	Dosage(cap/tab)	Monthly Quantity	Refill Frequency
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	Prescription Name (brand required?)	Dosage(Cap/Tab)	Monthly Quantity	Refill Frequency
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