Last Name:
First Name:
Middle Name:
Street Address:
Apt/Lot #:
City:
State:
Zip Code:
Phone No.:
Alternate No.:
Email:
Marital Status:
Gender:
Male
Female
U.S. Resident:
Yes
No
Date of Birth:
Date: / Month: / Year:
Number of People in the Household:
Total Household Income Per Year:
$
Do you have prescription drugs coverage of any kind? (Do not include Discount Cards or Programs):
Yes
No
Are you enrolled in a Medicare Part D Prescription Drug Plan?
Yes
No
If "Yes", when did you (or will you) enter the Donut Hole?
Month: / Year:
Do you have Health Insurance?
Yes
No
Check Types:
Medicare
VA
Private Insurance
Does this plan include prescription drug coverage?
Yes
No
MEDICATIONS:
To ensure we order the correct medications, please list all prescription medications currently
being taken or prescribed to you. Refer to prescription bottles for exact information and spelling
Drug Name
Dosage
Frequency
Monthly Cost
1
$
2
$
3
$
4
$
5
$
6
$
7
$
8
$
9
$
10
$