EmailMeForm
Name
*
Email
*
Phone #
*
Zip code
*
Which agent are you currently working with?
What Company and Plan Name do you currently have for Your Prescriptions?
(Look on your Advantage or Rx Card for these "Names")
What are your Top 3 Pharmacy Choices?
Do you prefer to get your medications at:
Pharmacy
Mail Order
Both
RX Drug Search
Drug Name
Dosage (MG Amount)
Times Per Day
30 or 90 Days?
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Provider Search
First Name
Last Name
Speciality
City
Zipcode
Provider 1
Provider 2
Provider 3
Provider 4
Provider 5
Comments/Additional Drugs or Doctors
By filling out this form you are attesting that you are only providing accurate and truthful information. Furthermore you are requesting us to respond and giving us permission to contact you for up to 12 full months.
Signature
Clear
