* required information
Prescription Information Form 
Contact Information
Your membership with My Advocate for Health entitles you to cost-cutting health benefits, significant savings on your prescription drugs and a free annual wellness panel. Find out if you qualify for free or significantly reduced cost medications. Call 727.455.8590 or complete this form and you will be contacted within 24 hours.
First Name:*
Last Name:*
Email:*
Mailing Address:
Apt/Box/Unit/Suite:
City:
State:
ZIP/Postal Code:*
Phone:*
How did you hear about Defeat Diabetes Foundation?:
If you chose, "other" as how you heard about Defeat Diabetes Foundation, please specify:
Yes, I would like to receive more information about Diabetes!: Yes
Additional Information
Best Time to Call:
Number of Prescriptions:
On Medicare?:* Yes
No
Current Cost of Medications per Month: