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Rx Profile
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Rx Profile
Name
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Last
Zip Code
Name of Your Agent
Please Select
Liz Harms
Kelly Stibbens
Jack Townsend
Rachel Townsend
Renee Townsend
Lori Moreland
1
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
2
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
3
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
4
Current Prescription Drugs
Form
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Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
5
Current Prescription Drugs
Form
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Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
6
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
7
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
8
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
9
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
10
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
11
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
12
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
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13
Current Prescription Drugs
Form
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Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
14
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
15
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
16
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
17
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
18
Current Prescription Drugs
Form
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Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
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3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
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180 Day
365 Days
Preferred Retail Pharmacy
19
Current Prescription Drugs
Form
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Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
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3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
20
Current Prescription Drugs
Form
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Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
20
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
21
Current Prescription Drugs
Form
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Aerosol
Bottle
Capsule
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Eye Drops
Gel
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Inhaler
Injection
Liquid
Lotions
Lozenge
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Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
22
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
23
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
24
Current Prescription Drugs
Form
Please Select Form
Aerosol
Bottle
Capsule
Cream
Eye Drops
Gel
Granules
Inhaler
Injection
Liquid
Lotions
Lozenge
Nasal Spray
Nebulizer
Ointments
Paste
Powder
Suppository
Tablet
Dosage Amount
Dosage Unit of Measure
Please Select Dosage Unit of Measure
mg
mcg
mEq
gm
kg
comp
oz
lbs
tbsp
mL
L
fl oz
pt
Usage Frequency
Please Select Usage Frequency
PRN (as needed)
1/day
2/day
3/day
4/day
5/day
6/day
7/day
8/day
1/wk
2/wk
3/wk
4/wk
5/wk
6/wk
1/mth
2/mth
3/mth
4/mth
5/mth
6/mth
1/yr
1 Bottle
2 Bottle
3 Bottle
4 Bottle
Refill Frequency (30 Day or 90 Day)
Please Select Refill Frequency
30 Day
90 Day
180 Day
365 Days
Preferred Retail Pharmacy
Notes
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