Medicare Check-Up Form Name * First Name Last Name Email * Phone * (###) ### #### Zip code * What is Your Preferred Pharmacy? Are you open to having your prescriptions mailed to you, if it saves you additional money? Yes No RX drug search: Medication Name / Dosage (MG Amount) / Times Per Day Provider Search: First and Last name / Specialty / City / Zip Code Comments/Additional Drugs or Doctors Thank you!
