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

By submitting your information, you agree that an authorized representative or licensed insurance

agent may contact you by phone or email to answer your questions or provide additional information

about Medicare Advantage or Prescription Drug Plans or Medicare Supplement Insurance plans. This is a

solicitation for insurance.

Let’s Talk!