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Tell us about any prescriptions you take and we will compare Part D plans for you. If you take none at all, just say so below — you can still send the form.
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Medication 11
Medication 12
Medication 13
Medication 14
Medication 15
There is room for 30 in total. If you take more than 30, send the rest to Danielledeluca9@gmail.com and we will add them.
Medication 16
Medication 17
Medication 18
Medication 19
Medication 20
Medication 21
Medication 22
Medication 23
Medication 24
Medication 25
Medication 26
Medication 27
Medication 28
Medication 29
Medication 30
List the doctors you see. Only the first is required.
