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Application Form

Thank you for reaching out to Teleaid. We are here to help uninsured and low-income individuals access the medications they need at a minimal cost. Please fill out the application below to determine your eligibility for our program.

Personal information
Financial Information
Do you currently have health insurance?
Do you receive medication subsidies from any other organizations or government programs?
Medical Information
Chronic Condition(s) Requiring Medication:
Prescription Information:
Please upload your prescription or schedule a free appointment with our in-house doctor.
Medications
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