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How much do you spend per month on your medications? *

Less than $100 per month Between $100 to $500 per month Between $500 to $1000 per month More than $1000 per month

Less than $25,000 per year Between $25,000 to $50,000 per year Between $50,000 to $75,000 per year More than $75,000 per year

Please enter all brand name medications you are taking.

Separate each medication by comma (e.g. Ozempic, Januvia)

First name

Last name

Phone number

I agree to the privacy policy. *

Please confirm if you agree in order to proceed.