Before Our Call: Send me a list of your Doctors and Prescriptions

Before Our Call: Send me a list of your Doctors and Prescriptions

For Medicare101.net clients of Danny Matheus, licensed Medicare agent. This takes about 10 minutes. Have your pill bottles nearby. Your answers help Danny find a plan that covers your doctors and your drugs.
About you
First name
Last name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
ZIP code
Your doctors
Add each doctor you see. Start with your main doctor, then any specialists.
Doctors
Please include your main doctor first, then any specialists you see.
If you have more than one doctor of the same kind, list each one separately.
Your medicines
Medicine 1 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 2 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 3 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 4 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 5 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 6 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 7 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 8 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 9 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 10 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 11 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 12 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 13 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 14 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Medicine 15 (type the first 3 letters, then tap your drug)
If you couldn't find it, type it here
Strength, like 10 mg
How often do you take it?
How many come in each refill?
How long does each refill last?
Brand name or generic?
Do you take another medicine?
Should be Empty: