Prescription and Pharmacy Listing
Please provide your current prescriptions and preferred pharmacy information below. This allows your agent to research plan options that align with your medication needs and pharmacy preferences.
What is your name?
First Name
Last Name
What is your email?
example@example.com
What is your phone number?
Please enter a valid phone number.
Please list all prescriptions that you take routinely or occasionally.
Prescription Name
Dosage
Type of drug (tablet, capsule, injection, etc.)
How often do you take this drug?
1
2
3
4
5
6
7
8
9
10
What pharmacy do you prefer to use?
Name of Pharmacy
Address
1
2
Is there any other information you would like to provide regarding your prescriptions?
If you need to list more prescriptions, please email the information to sarah@laughlinagency.com
Submit
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