Current Pharmacy Name
(VERY IMPORTANT)
Medications List
Please list your current medications.
• Be sure to provide the Complete Drug Name from Bottle/Container.
• DOSE/SIZE: Be sure to list BOTH dosage and container size for Inhalers, Drops, Lotions, Creams, Ointments and Gels.
• Please DO NOT list “AS NEEDED“ – Complete Refill Frequency with one of the available options.
• *Answer "Yes" if using GoodRx or any other discount drug plan to fill medication.
Drug Name
EXAMPLE: Metoprolol Succinate ER
Dosage/Size
EXAMPLE: 50mg
How Often Refilled
Quarterly
Drug Name
EXAMPLE: Albuterol Sulfate HFA
Dosage/Size
EXAMPLE: 90mcg/8.5g
How Often Refilled
Monthly
Form—Please choose an option— Tab Inhaler Cap Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Quarterly Monthly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— No Yes
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Check to add more Rx
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No
Form—Please choose an option— Tab Cap Inhaler Drops Patch Injection Vial Lotion Cream Ointment Gel Pen
How Often Refilled—Please choose an option— Monthly Quarterly Semi-Annually Annually Bi-Monthly
Generic OK?—Please choose an option— Yes No
Using GoodRx?—Please choose an option— Yes No