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Prescription List

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Send us Your RX List, Dosage, and Preferred Pharmacy and We Will Contact You about Your RX Plan!

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Client Name

First Name Last Name

Phone

RX 1-4

(ex: levothyroxine 40mcg, atorvastatin 50 mg, metoprolol succinate 50 mg, Xarelto 20 mg

RX 5-10

Preferred Pharmacy:

Additional RX:

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