530-628-9676

Rx Drug Lookup Form

Complete the below form and someone from our office will contact you as soon as possible.

First Name

Last Name

Email Address

Phone Number

ZIP Code

What is your preferred pharmacy?

Are you open to having your prescriptions mailed to you, if it saves you additional money?

Yes

Medication 1

Drug Name

Dosage

Times Per Day

Medication 2

Drug Name

Dosage

Times Per Day

Medication 3

Drug Name

Dosage

Times Per Day

Medication 4

Drug Name

Dosage

Times Per Day

Medication 5

Drug Name

Dosage

Times Per Day

Medication 6

Drug Name

Dosage

Times Per Day

Medication 7

Drug Name

Dosage

Times Per Day

Medication 8

Drug Name

Dosage

Times Per Day

Medication 9

Drug Name

Dosage

Times Per Day

Medication 10

Drug Name

Dosage

Times Per Day

Provider 1

First Name

Last Name

Specialty

City

Zip

Provider 2

First Name

Last Name

Specialty

City

Zip

Provider 3

First Name

Last Name

Specialty

City

Zip

Provider 4

First Name

Last Name

Specialty

City

Zip

Provider 5

First Name

Last Name

Specialty

City

Zip

Comments / Additional Drugs or Doctors

By completing this form you agree that a licensed insurance agent may contact you by phone or email to answer any questions you have regarding Medicare plans. This is a solicitation for insurance.

Rx Drug Lookup Form

Rx Drug Lookup Form

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