Medicare / RX and Dr Questionnaire

RX and Doctor Questionnaire

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Tell us about yourself.

Name*

Email*

Phone*

Date of Birth

State*

County*

Now, let's talk prescriptions.

Current Insurance Plan

Preferred Pharmacy

Do you use mail order?

What medications are you currently taking?

RX Name: Name of the medicine
Strength: Amount of the active ingredient (example: “150mg”)
Dosage: Amount to be taken (example: “2 tablets”)
Refill Quantity: Quantity in each refill (example: “30”)
Refill Frequency: How often the prescription is refilled (example: “1 month”)
Generic OK?: Generic substitutions are OK (example: “yes”)

RX Name

Strength

Dosage

Refill Quantity

Refill Frequency

Generic OK?

Primary Care Physician

Clinic Name

Specialists

Name

Phone #

Specialty

Preferred Hospitals

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Phone

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For Businesses

Individuals & Families

Insights

About

RX and Doctor Questionnaire

Tell us about yourself.

Now, let's talk prescriptions.