Medical Savings Plan
1272 Jungerman Rd.
St. Peters, MO 63376

800-350-5066
(636) 922-0048
medsave@swbell.net
* Are Requiered
*Full Name
*Address
*City
*State
*Zip
E-Mail
*Age
Sex Male Female
Spouse Sex: Male Female
Date of Birth / /
No. of Children
(All additional add-ons
are covered under
family pricing)
*Home Phone No.
*Work Phone No.
Fax No.
Best Time to Call AM PM
Best Place to Call Home Work
Name of
Agent/Broker 		and Telephone No.
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hear about us?
Medical Savings Plans and Pricing
(Chose the plan your most intrested in.)
Plan Individual Family
Best Benefits
Dental, Prescription,
Vitamin, Vision, Hearing,
Chiropractic		 $9.95 $12.95
Combo Plan Includes:
Best Benefits and
Accident Plan		 $19.95 $25.95
Deluxe Plan Includes:
All the above, plus
Physician Services		 $29.95 $39.95
Stand Alone or Option
Dental $5.95 $7.95
Prescription/Vision $6.95 $8.95
Physician Services $14.95 $19.95
Accident $14.95 $19.95
List of Medications
You will be called back with price comparison.
(Remember: All Information Is Sent Securely)
Present Medication:

 Supply:
30 or 90 day		 Daly Usage:
1x or 2x		 My Dosage:
1. 30 90 1 2
2. 30 90 1 2
3. 30 90 1 2
4. 30 90 1 2
5. 30 90 1 2
6. 30 90 1 2
7. 30 90 1 2
8. 30 90 1 2