Physician and Prescription Drug Form Update
Please complete form if you work with Jim Poling from Citizen Advisory Group
Client Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Pharmacy
Please List Your Medications. You do not need to list OTC supplements/medications.
(Medication #1) List Medication Name, Dosage, and Frequency
(Medication #2 List Medication Name, Dosage, and Frequency
(Medication #3) List Medication Name, Dosage, and Frequency
(Medication #4) List Medication Name, Dosage, and Frequency
(Medication #5) List Medication Name, Dosage, and Frequency
(Medication #6) List Medication Name, Dosage, and Frequency
(Medication #7) List Medication Name, Dosage, and Frequency
(Medication #8) List Medication Name, Dosage, and Frequency
(Medication #9) List Medication Name, Dosage, and Frequency
(Medication #10) List Medication Name, Dosage, and Frequency
Please list any additional medications (include name, dosage, and frequency)
Primary Care Physician (Full Name)
List ALL Specialists (Full Name)
Preferred Hospital/System
Are you satisfied with your current plan? (Please explain your answer)
If you currently have a Medicare Supplement are you interested in changing to a Medicare Advantage Plan? (Please explain your answer)
Are you interested in a Dental Plan? If yes, please provide name of dentist.
Preferred Meeting Method
*
Please Select
CONFERENCE CALL/VIRTUAL
IN OFFICE MEETING
NOT REQUESTING A MEETING
Additional Comments
Submit
Should be Empty: