Medication update
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Photo of Jordan Avery

A request from

Jordan Avery

Licensed Medicare Agent · Avery Benefits Group

Sharing your medication list lets me find the plan that covers your prescriptions at the lowest cost.

(602) 555-0142demo.agent@sharemyrx.com

Please confirm your details and list your current medications. Fields marked * are required. Your answers are saved on this device as you go.

Your information

This form is for Margaret Holloway. Your name and email were entered by Jordan Avery and can’t be changed here, so it’s fine if you share an inbox or use a different email day to day.

On file with your agent. It only needs to be the address your agent uses to reach you.

Preferred pharmacy

Primary physician

Start typing a first or last name and pick from the list, or just type the name.

Medicare details

For your security we don't pre-fill this. The number on file ends in MK72. Enter all 11 characters from your red, white, and blue card.

Current drug coverage

Your medications

Add every prescription you take regularly. Search by name, then choose the strength and how often you take it.

Medication 1

Pick your medication from the list that appears.

Your information is private and only shared with Jordan Avery.