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Medication Assistance Intake Form

Tell us about the medications you need help paying for. Checking your medication is free — and if it is on our list, we provide the forms for free. When you click Submit, your form is sent straight to Jessica.

About You

Full name *

Date of birth *

Phone *

Email *

City & State

Best way to reach you

Who told you about us?

Who Is This For?

This intake is: For me For my child (under 18) For my adult child (18–26) For another family member

If not for you — their full name

Their date of birth

Your relationship to them

Your Medications

Medications you need help paying for (name, dose, and who prescribes it): *

About what do you pay for medication each month? ($)

Do you have drug coverage? (check all that apply) Medicare Medicaid Private insurance VA None

Pharmacy you use

Pharmacy phone

Do you ever skip doses or split pills because of cost? Yes No

Have you ever used a manufacturer assistance program (free medicine from the drug company)? Yes No Not sure

Free Checks — Have You Tried These?

Check any you have tried: GoodRx (goodrx.com) Cost Plus Drugs (costplusdrugs.com) Southern Oak's free medication checker Not yet

Checking your medication is free, and if it is on our list of 500+ medications, we provide the manufacturer program forms for free. For the full program application, we will also send you our Rx Assist Application to complete.

Your main doctor for these medications

Clinic

* I understand the information above is correct.

Your answers go straight to Jessica at Southern Oak Financial & Wellness. We do not sell or share your information.

Southern Oak Financial & Wellness

Email: southernoakfw@gmail.com
Website: Southernoakfw.org
San Antonio, TX — Serving San Antonio, the Rio Grande Valley & surrounding cities

DISCLAIMER: We do not provide refunds for services; there is NO guarantee of approvals, and we are not legal attorneys.