Prescription Drug Report Request

  • Please list all regular maintenance prescription drugs you are currently taking

  • Name of the Prescription (if filled as a Generic you must list the Generic name)Strength (milligrams, micrograms, or units)Dosage (how often do you take) 
  • To add an additional prescription, click the plus button

  • List two preferred Pharmacies

  • Contact Details

  • Once completed and signed, please email to Gigi Stellema:

    Please note, until we have received both forms, we are not at liberty to discuss the Medicare plan options.