Trozan Insurance Medication List Request Form
This is a secure way to send your medication list safely to our office.
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Email *
Your Name *
Today's date (NOT your birthday):
Your Phone Number *
Your physical street address (not a PO Box) *
What Pharmacy do you Prefer to use? If you use Mail Order, please let us know AND if you needed a quick prescription, which local pharmacy would you use? *
If you could save money on your prescriptions, would you be willing to change your pharmacy? *
Are any of your medications given (infusions, injections, etc.) to you at your doctor's office? If yes, please list below: No *
Do you take any prescribed medications *
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Do you use any inhalers? If so, please mark which one below: *
Required
How often do you get an inhaler? And how many do you get each time (i.e. - 1 inhaler every month, 3 inhalers every 6 months, 2 inhalers every year, etc.)? If you don't use an inhaler, just put N/A below. *
Exact Name of Medication (Please use the EXACT name shown on the bottle/tube/spray, We need to know if you take the generic or brand name)                                                                Metoprolol 
What FORM does this medication come in?  (Your bottle may say TAB for tablet or CAP for capsule)
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What is the DOSAGE of this medication? (ex. 20 mg tablet, 150 MGC, 1%)  If it is a cream/liquid/etc, what size is the bottle? (15mL, 40gm, etc)    
How often do you TAKE this medication?
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If you marked AS NEEDED: please give us an estimate on how many pills (or tubes or sprays) you get in a year
Do you fill this prescription through GoodRx, a discount plan, or your Medicare plan
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Exact Name of Medication (Please use the EXACT name shown on the bottle/tube/spray, We need to know if you take the generic or brand name)                                                                
What FORM does the medication come in?  (Your bottle may say TAB for tablet or CAP for capsule)
Clear selection
What is the DOSAGE of this medication? (ex. 20 mg tablet, 150 MGC, 1%)  If it is a cream/liquid/etc, what size is the bottle? (15mL, 40gm, etc)    
How often do you TAKE this medication?
Clear selection
If you marked AS NEEDED: please give us an estimate on how many pills (tubes, sprays, etc.) you get in a year
Do you fill this prescription through GoodRx, discount plan, or your Medicare plan
Clear selection
Exact Name of Medication (Please use the EXACT name shown on the bottle/tube/spray, We need to know if you take the generic or brand name)                                                                
What FORM does the medication come in?  (Your bottle may say TAB for tablet or CAP for capsule)
Clear selection
What is the DOSAGE of this medication? (ex. 20 mg tablet, 150 MGC, 1%)  If it is a cream/liquid/etc, what size is the bottle? (15mL, 40gm, etc)           
How often do you TAKE this medication?
Clear selection
If you marked AS NEEDED: please give us an estimate on how many pills (tubes, sprays, etc.) you get in a year
Do you fill this prescription through GoodRx, a discount plan, or your Medicare plan
Clear selection
Exact Name of Medication (Please use the EXACT name shown on the bottle/tube/spray, We need to know if you take the generic or brand name)                                                                
What FORM does the Medication come in? (Your bottle may say TAB for tablet or CAP for capsule)
Clear selection
What is the DOSAGE of this medication? (ex. 20 mg tablet, 150 MGC, 1%)  If it is a cream/liquid/etc, what size is the bottle? (15mL, 40gm, etc)    
How often do you TAKE this medication?
Clear selection
If you marked AS NEEDED: please give us an estimate on how many pills (tubes, sprays, etc.) you get in a year
Do you fill this prescription through GoodRx, a discount plan, or your Medicare plan
Clear selection
List any more Medications Below      Please be sure to add Exact Medication Name, the Dose, is it a Tablet/Capsule/Spray/Lotion/Etc., How Often you take each medication each day (or as needed), and if you use GoodRx, a discount plan, or your Medicare plan to fill each one. If you fill "As Needed" put in the most you think you'll get in a year
Is there anything else you think we should know?
MEDICARE ADVANTAGE PLANS ONLY: If you have a Medicare Advantage Plan, please list the names of any medical providers you see (Primary Care, dentist, optometrist, chiropractors, etc.)
A copy of your responses will be emailed to the address you provided.
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