★ Rx Drug Lookup Form

Let Us Look up Your Prescription Medication

Contact Us

First Name

Last Name

Phone

Zip Code

Preferred Pharmacy

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

Yes

Medication 1

Medication 1

Dosage

Times Per Day

Medication 2

Medication 2

Dosage

Times Per Day

Medication 3

Medication 3

Dosage

Times Per Day

Medication 4

Medication 4

Dosage

Times Per Day

Medication 5

Medication 5

Dosage

Times Per Day

Provider 1

Provider 1

Name

Specialty

Address

Provider 2

Provider 2

Name

Specialty

Address

Provider 3

Provider 3

Name

Specialty

Address

Provider 4

Provider 4

Name

Specialty

Address

Provider 5

Provider 5

Name

Specialty

Address

Additional comments

Opt-In

By checking, I agree to be contacted by a licenced insurance agent from Embrace Health Insurance Agency to review my medication costs.

We’re only a phone call away! Call 909-521-8838 and let us know how we can help.

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CONTACT DETAILS

Phone: 909-521-8838

Email: charr-insurance@outlook.com

BUSINESS HOURS

Mon - Sun: 9:00 am - 5:00 pm

We do not offer every plan available in your area. Currently, we represent 8 organizations which offer 75 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information

Agency LIC #6011448

OUR LOCATION

123 E. 9th Street #341

Upland, CA 91786