Rx Drug Lookup Form

Request a Drug Look Up. Complete the below form and someone from our office will contact you as soon as possible.

Drug Lookup form

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Name(Required)

First Last

Email(Required)

Phone(Required)

Zip Code(Required)

What is your preferred pharmacy?

Are you open to having your prescriptions mailed to you, if it saves you additional money?

Yes

Medications

Medication 1 -Drug Name

Dosage (MG Amount)

Times per day

Medication 2 -Drug Name

Dosage (MG Amount)

Times per day

Medication 3 -Drug Name

Dosage (MG Amount)

Times per day

Medication 4 -Drug Name

Dosage (MG Amount)

Times per day

Medication 5 -Drug Name

Dosage (MG Amount)

Times per day

Medication 6 -Drug Name

Dosage (MG Amount)

Times per day

Medication 7 -Drug Name

Dosage (MG Amount)

Times per day

Medication 8 -Drug Name

Dosage (MG Amount)

Times per day

Medication 9 -Drug Name

Dosage (MG Amount)

Times per day

Medication 10 -Drug Name

Dosage (MG Amount)

Times per day

Providers Details

Provider 1 - First & Last name

Specialty

City

Zip code

Provider 2 - First & Last name

Specialty

City

Zip code

Provider 3 - First & Last name

Specialty

City

Zip code

Provider 4 - First & Last name

Specialty

City

Zip code

Provider 5 - First & Last name

Specialty

City

Zip code

Comments/Additional Drugs or Doctors

Never a Cost for My Services!

(760) 258-4900

Rx Drug Lookup Form

Request a Drug Look Up. Complete the below form and someone from our office will contact you as soon as possible.

Drug Lookup form

Next Steps: Sync an Email Add-On

Medications

Providers Details

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