RX Drug Lookup Form

RX Drug Lookup Form

Name*

Email*

Phone #*

Zip Code*

What is Your Preferred Pharmacy?

Message:

Are you open to having your prescriptions mailed to you, if it saves you additional money?

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RX Drug Search

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Medication 1

Drug Name

Dosage (MG Amount)

Times Per Day

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Medication 2

Drug Name

Dosage (MG Amount)

Times Per Day

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Medication 3

Drug Name

Dosage (MG Amount)

Times Per Day

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Medication 4

Drug Name

Dosage (MG Amount)

Times Per Day

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Medication 5

Drug Name

Dosage (MG Amount)

Times Per Day

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Medication 6

Drug Name

Dosage (MG Amount)

Times Per Day

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Medication 7

Drug Name

Dosage (MG Amount)

Times Per Day

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Medication 8

Drug Name

Dosage (MG Amount)

Times Per Day

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Medication 9

Drug Name

Dosage (MG Amount)

Times Per Day

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Medication 10

Drug Name

Dosage (MG Amount)

Times Per Day

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Provider Search

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Provider 1

First Name

Last Name

Speciality

City

Zipcode

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Provider 2

First Name

Last Name

Speciality

City

Zipcode

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Provider 3

First Name

Last Name

Speciality

City

Zipcode

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Provider 4

First Name

Last Name

Speciality

City

Zipcode

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Provider 5

First Name

Last Name

Speciality

City

Zipcode

Comments/Additional Drugs or Doctors

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CONTACT INFORMATION

marcos@theretirementcafe.net

(531) 999-0509

mandy@theretirementcafe.net

(402) 850-4291

BUSINESS HOURS

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Evenings and Weekends By Request

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