Rx Shopping Request Form | Mysite

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904-737-3636

Gardner & Company

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Rx Shopping Request Form

Thanks for submitting your Rx list! We'll get back to you soon to schedule a time to review your results.

First Name

Middle Name

Last Name

Date of Birth

Address

State

Zipcode

City

County

Phone

Email

Preferred Pharmacy

Current Part D (Medicare Rx) Plan

Other Part D Plan Name

How Many Prescriptions Do You Take?

Medication 1 Name

Medication 1 Dosage

Medication 1 Frequency

Medication 1 Refill Frequency

Medication 2 Name

Medication 2 Dosage

Medication 2 Frequency

Medication 2 Refill Frequency

Medication 3 Name

Medication 3 Dosage

Medication 3 Frequency

Medication 3 Refill Frequency

Medication 4 Name

Medication 4 Dosage

Medication 4 Frequency

Medication 4 Refill Frequency

Medication 5 Name

Medication 5 Dosage

Medication 5 Frequency

Medication 5 Refill Frequency

Medication 6 Name

Medication 6 Dosage

Medication 6 Frequency

Medication 6 Refill Frequency

Medication 7 Name

Medication 7 Dosage

Medication 7 Frequency

Medication 7 Refill Frequency

Medication 8 Name

Medication 8 Dosage

Medication 8 Frequency

Medication 8 Refill Frequency

Medication 9 Name

Medication 9 Dosage

Medication 9 Frequency

Medication 9 Refill Frequency

Medication 10 Name

Medication 10 Dosage

Medication 10 Frequency

Medication 10 Refill Frequency

Medication 11 Name

Medication 11 Dosage

Medication 11 Frequency

Medication 11 Refill Frequency

Medication 12 Name

Medication 12 Dosage

Medication 12 Frequency

Medication 12 Refill Frequency

Medication 13 Name

Medication 13 Dosage

Medication 13 Frequency

Medication 13 Refill Frequency

Medication 14 Name

Medication 14 Dosage

Medication 14 Frequency

Medication 14 Refill Frequency

Medication 15 Name

Medication 15 Dosage

Medication 15 Frequency

Medication 15 Refill Frequency

Medication 16 Name

Medication 16 Dosage

Medication 16 Frequency

Medication 16 Refill Frequency

Medication 17 Name

Medication 17 Dosage

Medication 17 Frequency

Medication 17 Refill Frequency

Medication 18 Name

Medication 18 Dosage

Medication 18 Frequency

Medication 18 Refill Frequency

Medication 19 Name

Medication 19 Dosage

Medication 19 Frequency

Medication 19 Refill Frequency

Medication 20 Name

Medication 20 Dosage

Medication 20 Frequency

Medication 20 Refill Frequency

Additional Information

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