Prescription Drug Information
In order to construct an accurate cost analysis, we will need your complete and correct drug information. For example, it is important to indicate the name of the drug that you are taking, and whether you are taking a BRAND or GENERIC version. Please note, over-the-counter medications, vitamins, and supplements are not covered by prescription drug plans and therefore are not required on this form.
Please complete one form per person. Be sure to fax or mail this form 10-14 days prior to your scheduled consultation. Additional instructions can be found on the form.