Seniormark - Medication Input Form & Prescription Information

This form is being submitted for:*

Do you currently take any prescription medications?

Yes

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.

RX Name

RX Type (Brand or Generic)

Dosage

How Often?

(Click ⊕ at end of row to enter additional medications)

Pharmacy Information

Preferred Pharmacy*

Would you be willing to use a different pharmacy if it saves you money?*

Yes

Consent*

By checking this box, 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. 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.

This field is for validation purposes and should be left unchanged.