Prescription Drug Form

    Please Enter Your Contact Information

    Other Information

    Medicaid & Social Security

    Do you receive extra help from Medicaid or Social Security? *noyes

    Address and traveling

    Do you live at a different address between October 15th and December 7th? * noyes

    Insulin

    Do you use insulin? *: noyes

    Inhalers & Nebulizers

    Do you use an Inhaler or Nebulizer? *: noyes

    Creams, Gels, Ointments, Lotions & Shampoos

    Do you use medicated creams, gels, ointments, lotions or shampoos? *: noyes



    Prescription Information

    Do you take medication? *: noyes

    Medication

    Pharmacy Information

    yesno