Prescription Drug Fact Finder

Client Name*
Please enter one entry for each spouse
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Email
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Prescription Drug(s) Currently Prescribed
Substitute Generics for Brand?
- Yes
- No
Preferred Pharamcy
Current Prescription Drug Plan Name
Switch Pharmacies to Save?
- Yes
- No
1. Name of Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank. Include numbers only please.
Mg or ML Mg or ML
Frequency
2. Name of Drug
Dosage
Mg or ML
Frequency
3. Name of Drug
Dosage
Mg or ML
Frequency
4. Name of Drug
Dosage
Mg or ML
Frequency
5. Name of Drug
Dosage
Mg or ML
Frequency
6. Name of Drug
Dosage
Mg or ML
Frequency
7. Name of Drug
Dosage
Mg or ML
Frequency
8. Name of Drug
Dosage
Mg or ML
Frequency
9. Name of Drug
Dosage
Mg or ML
Frequency
10. Name of Drug
Dosage
Mg or ML
Frequency
11. Name of Drug
Dosage
Mg or ML
Frequency
12. Name of Drug
Dosage
Mg or ML
Frequency
13. Name of Drug
Dosage
Mg or ML
Frequency
14. Name of Drug
Dosage
Mg or ML
Frequency
15. Name of Drug
Dosage
Mg or ML
Frequency
Additional Information

Prescription Drug(s) Currently Prescribed