Rx List

Please complete this form prior to our appointment. PLEASE BE AS SPECIFIC AS REQUESTED. This information is used to determine the best Drug plan for your specific needs. Thank you!

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RX List

First & Last Name

Address: City, State, ZIP

Preferred Pharmacy & Location

Prescription #1: Name, Dose, Times of Day, Quantity of box/bottle, Monthly or Quarterly, Mail Order (Y or N)

Prescription #2: Name, Dose, Times of Day, Quantity of box/bottle, Monthly or Quarterly, Mail Order (Y or N)

Prescription #3: Name, Dose, Times of Day, Quantity of box/bottle, Monthly or Quarterly, Mail Order (Y or N)

Prescription #4: Name, Dose, Times of Day, Quantity of box/bottle, Monthly or Quarterly, Mail Order (Y or N)

Prescription #5: Name, Dose, Times of Day, Quantity of box/bottle, Monthly or Quarterly, Mail Order (Y or N)

Prescription #6: Name, Dose, Times of Day, Quantity of box/bottle, Monthly or Quarterly, Mail Order (Y or N)

Prescription #7: Name, Dose, Times of Day, Quantity of box/bottle, Monthly or Quarterly, Mail Order (Y or N)

Prescription #8: Name, Dose, Times of Day, Quantity of box/bottle, Monthly or Quarterly, Mail Order (Y or N)

Prescription #9: Name, Dose, Times of Day, Quantity of box/bottle, Monthly or Quarterly, Mail Order (Y or N)

Prescription #10: Name, Dose, Times of Day, Quantity of box/bottle, Monthly or Quarterly, Mail Order (Y or N)

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