My Medication List

Name

Date

Please list your current Prescription Drugs

• 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.
• Answer "Yes" if using GoodRx or any other discount drug plan to fill medication.

Please list your current medications

Drug Name

Dosage/Size

Form

Quantity Per Refill

How Often Refilled

Generic OK?

Using GoodRx?

Drug Name

Dosage/Size

Form

Quantity Per Refill

How Often Refilled

Generic OK?

Using GoodRx?

Drug Name

Dosage/Size

Form

Quantity Per Refill

How Often Refilled

Generic OK?

Using GoodRx?

Drug Name

Dosage/Size

Form

Quantity Per Refill

How Often Refilled

Generic OK?

Using GoodRx?

Have additional medication? Check Yes to add more Rx.

Yes

If you are done adding your medications CLICK SUBMIT.

More Medications

Drug Name

Dosage/Size

Form

Quantity Per Refill

How Often Refilled

Generic OK?

Using GoodRx?

Drug Name

Dosage/Size

Form

Quantity Per Refill

How Often Refilled

Generic OK?

Using GoodRx?

Drug Name

Dosage/Size

Form

Quantity Per Refill

How Often Refilled

Generic OK?

Using GoodRx?

Drug Name

Dosage/Size

Form

Quantity Per Refill

How Often Refilled

Generic OK?

Using GoodRx?

more meds-new form

To add more medications CHECK YES; then CLICK SUBMIT (another medication page will load)

Yes

Please list your current Prescription Drugs

Please list your current medications

If you are done adding your medications CLICK SUBMIT.

More Medications

more meds-new form

Otherwise, if you are done adding your medications CLICK SUBMIT.

Unlocking The Right Medicare Plan For You

Jenell Sobas, FPQP®