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Reviews Form

General Information
Year
Name
Address
Phone Number
Email Address
Date of Birth
Date of Birth

Do You have a Connect Card from the state of Connecticut?
Do You have a Connect Card from the state of Connecticut?
Do You Receive Prescription Drug Assistance?
Notes / RT Notes
Preferred Method of Contact
Your Primary Care Physician
Dr.
Address:
Phone:
Your Specialist Information
Specialist Name
Type of Specialist
Address of Office / Group Name
Phone Number
 
Your Prescription Information
Name of medication
Dosage (mg, ml)
30 Day Supply
60 Day Supply
90 Day Supply
Pharmacy
 
If you prescription were cheaper at another pharmacy, would you consider switching pharmacies?
If you prescription were cheaper at another pharmacy, would you consider switching pharmacies?
Are you a diabetic?
Are you a diabetic?

Open Hours

Mon-Fri: 9:00am – 4:00pmClosed for lunch: 12:00-12:30Saturday: By Appointment Only

Address

195 West Main StreetNew Britain, CT 06052
By appointment only: 360 North Main Street Suite 5Southington, CT 06489

Get In Touch

Telephone: 203-699-2611Email: raymondseniorplanning@gmail.com

Let's insure a healthy future together.

Contact us!

Name
Consent(Required)
New Britain Location

195 West Main Street,
New Britain, CT 06052

New Britain Location Hours

Mon-Fri: 9:00am-4:00pm
Closed for lunch: 12:00-12:30
Saturday: By Appointment Only

Telephone: (203) 699-2611
Text Only: (860) 270-0840

Southington Location

By Appointment Only

360 North Main Street Suite 5,
Southington CT, 06489

(203) 699-2611

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