EmailMeForm
Full Legal Name
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Your Email Address
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Your Mobile Phone #
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What is Your Preferred Pharmacy?
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Full Physical Pharmacy Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Are you open to having your prescriptions mailed to you, if it saves you additional money?
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Yes
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RX Drug Search
Full Drug Name - From Label
Medication Form (Tablet, Capsule, Inhaler, Injection, Cream, Solution?)
Dosage (Strength)
How Many Times Per Day Per Instructions on label
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Provider Search
First Name
Last Name
Speciality
Address
City
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Comments /
Additional Drugs or Doctors
By checking YES I agree to have a Medicare Insurance agent contact me.
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YES
