Medical Review Form (Current Clients)

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Please list your preferred Hospital and preferred Retail Pharmacy below:

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E.g. OHSU/Walgreens

Please list your current Primary Care Physician:

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E.g. Dr. John Smith

Please list your current Specialists:

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<img alt='' title='Remove this row' data-src='https://medicarehelpnow.com/wp-content/plugins/gravityforms/images/list-remove.svg' class='lazyload' src='data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==' /><noscript><img alt='' title='Remove this row' data-src='https://medicarehelpnow.com/wp-content/plugins/gravityforms/images/list-remove.svg' class='lazyload' src='data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==' /><noscript><img src='https://medicarehelpnow.com/wp-content/plugins/gravityforms/images/list-remove.svg' alt='' title='Remove this row' />

E.g. Dr. Jane Smith (Cardiologist)

Prescription List:

Name of Prescription	Per Day	Dosage	30 or 90 day refill

E.g. Atorvastatin/once/40mg/30

Document Upload
Max. file size: 256 MB.
Current Medication List

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