Borislow Medicare Consultation Form

Preparing for your Medicare Consultation

*Name: 
*Address: 
*Phone:  
*DOB: 
*Medicare Claim # (If you have it yet) 
*Part A and/or Part B dates (if enrolled yet) 
*List of Medications including mgs per pill and frequency taken 
*Top two choices of pharmacies 
Current health insurance carrier

Please call or email the above information to set up appointment!

Ted O'Connor  
ted@borislow.com 
781-879-8434

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