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Medication Therapy Management Questionnaire

Why do I want a comprehensive Medication Therapy Management review?

  • Drug interactions
  • Vitamin recommendations
  • Better therapy options with less side effects
  • Important side effect information
  • Cannon can connect you with manufacturer discounts, possibly lowering your brand copay to $0
  • How and when is best to take your medications
  • New ideas to save money!

Form must be filled out in its entirety to qualify

  • Yes
    No
    Have you had your shingles vaccine?
    Are you interested in the new Pneumonia vaccine?
    Do you qualify for extra help with your prescription drugs?
    Would you like to receive all your medications on the same day each month?
  • Including name of medication, quantity & frequency
  • Type in your name to serve as your signature

* By signing this form, you are agreeing to our HIPAA agreement and give Cannon Pharmacy permission to contact you via phone. See our privacy policy or ask a Cannon Pharmacist for details.