RX Drug Lookup Form First & Last Name* Email Address* Phone* Zip Code* What is Your Preferred Pharmacy? Are you open to having your prescriptions mailed to you, if it saves you additional money? Are you open to having your prescriptions mailed to you, if it saves you additional money?YesNo Medication 1 Name Medication 1 Dosage/Times Per Day Medication 2 Name Medication 2 Dosage/Times Per Day Medication 3 Name Medication 3 Dosage/Times Per Day Medication 4 Name Medication 4 Dosage/Times Per Day Medication 5 Name Medication 5 Dosage/Times Per Day Provider 1 Name Provider 1 Info Provider 2 Name Provider 2 Info Provider 3 Name Provider 3 Info Provider 4 Name Provider 4 Info Provider 5 Name Provider 5 Info Additional Comments 5 + 11 = Submit By completing this form you agree that a licensed insurance agent may contact you by phone or email to answer any questions you have regarding Medicare plans. This is a solicitation for insurance.