Medicare Product Analysis Form

Please use Google Chrome or Microsoft Edge to complete this form. If you continue to have issues, reach out to your advisor at NateE@horanassoc.com, HeatherB@horanassoc.com or ChrisM@horanassoc.com.

Name
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Medication(s)

Please list all of your prescribed medications, excluding over-the-counter supplements.

Medications Dosage (ex. 20 mg) Frequency (times/day)

Preferred Doctor(s) & Hospital(s)

First Name Last Name Speciality