Medication Input Form

  • Prescription Information

    Please list all current prescription medications as listed on your medication bottles. List only medications prescribed by your doctor. Exclude over-the-counter items. Please list the generic name if you take generic medications. If you are taking injectables / inhalers / eyedrops / cremes, please list the number of vials / inhalers / bottles / tubes you use per month.
  • Pharmacy Information

  • Additional Comments

    *Please use this section to identify any additional medications if you have more than 10.
  • Authorization

    I have willingly provided the health information on this page to Seniormark, LLC, to assist in my selection of an individual health plan. I am seeking their recommendation for a Medicare plan that will meet my needs. This is a solicitation of insurance. By providing this information, I agree that an authorized representative or licensed insurance agent/producer may contact me by phone, e-mail, or mail to answer my questions or provide additional information about Medicare Supplement Insurance, Medicare Advantage, or Part D plans. I understand the information on this form is not to be used for any purpose other than to assist in my Medicare health plan selection, I am not bound to accept their recommendation, and this service is offered at no cost to me. This authorization expires 120 days after my signature date.
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.