https://findprescriptionrelief.com/wp-content/plugins/nex-forms
http://localhost:3000/patient-med-app?first_name={{first_name}}
redirect
Thank you for connecting with us. We will respond to you shortly.
1
https://findprescriptionrelief.com/wp-admin/admin-ajax.php
https://findprescriptionrelief.com/patient-application
yes
Introduction
Eligibility
Contact
Notes
Confirmation
Hi Im Maya. Ill take you through this easy application to qualify for Medication Cost Assistance. Ready? Enter your information below to begin.
First Name
Last Name
*Phone
Email
APPLY ONLINE
Great to meet you
{{first_name}}
! First, there's a few things I need to ask to help you...
Are you in the donut hole or will you be soon?
--- Select ---
No
Yes
Does your insurance cover all medication?
--- Select ---
No
Yes
How many people reside in your home?
1 person(s)
How much is your approximate household income monthly?
$ 500 dollars
CONTINUE
Good News! Looks can we help you
{{first_name}}
.
How would you like to enroll for drug assistance?
--- Select ---
I would like a call to Apply
I would like to Apply Online
I need to ask More Questions
CONTINUE
Fantastic, now please give us any special requests and we will get on with your choice of
{{how_would_you_like_to_enroll_for_drug_assistance}}
.
Comments & Special Requests
CONTINUE
Thank You
{{first_name}}
,
We will be in contact via your request you said:
{{how_would_you_like_to_enroll_for_drug_assistance}}
using your contact information
PHONE: {{phone_number}}
EMAIL: {{email}}
COMPLETE SUBMISSION