Pre-Appointment Information Form

Complete the below form and someone from our office will contact you as soon as possible.
Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
ZIP Code*
What is your preferred pharmacy(ies)?*
Are you open to having your prescriptions mailed to you, if it saves you additional money?

YesNo
Medication 1
Drug Name
Dosage (mg, mcg, pen, inhaler, ointment, etc.)
Times Per Day/Week/Month/Year (include which time length)
Medication 2
Drug Name
Dosage (mg, mcg, pen, inhaler, ointment, etc.)
Times Per Day/Week/Month/Year (include which time length)
Medication 3
Drug Name
Dosage (mg, mcg, pen, inhaler, ointment, etc.)
Times Per Day/Week/Month/Year (include which time length)
Medication 4
Drug Name
Dosage (mg, mcg, pen, inhaler, ointment, etc.)
Times Per Day/Week/Month/Year (include which time length)
Medication 5
Drug Name
Dosage (mg, mcg, pen, inhaler, ointment, etc.)
Times Per Day/Week/Month/Year (include which time length)
Medication 6
Drug Name
Dosage (mg, mcg, pen, inhaler, ointment, etc.)
Times Per Day/Week/Month/Year (include which time length)
Medication 7
Drug Name
Dosage (mg, mcg, pen, inhaler, ointment, etc.)
Times Per Day/Week/Month/Year (include which time length)
Medication 8
Drug Name
Dosage (mg, mcg, pen, inhaler, ointment, etc.)
Times Per Day/Week/Month/Year (include which time length)
Medication 9
Drug Name
Dosage (mg, mcg, pen, inhaler, ointment, etc.)
Times Per Day/Week/Month/Year (include which time length)
Medication 10
Drug Name
Dosage (mg, mcg, pen, inhaler, ointment, etc.)
Times Per Day/Week/Month/Year (include which time length)
Provider -Primary Care Doctor
Name

First NameLast Name
Specialty
City
Provider 2
Name

First NameLast Name
Specialty
City
Provider 3
Name

First NameLast Name
Specialty
City
Provider 4
Name

First NameLast Name
Specialty
City
Provider 5
Name

First NameLast Name
Specialty
City
Comments /Additional Drugs or Doctors
By completing this form you agree that a licensed insurance agent may contact you by phone or email to answer any questions you have regarding Medicare plans. This is a solicitation for insurance.

While we are appointed with all the major carriers who work with brokers, we do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. Encore Life Health and its agents are independent brokers and are not Medicare employees.

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Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication 7

Medication 8

Medication 9

Medication 10

Provider -Primary Care Doctor

Provider 2

Provider 3

Provider 4

Provider 5