5th Quarter – Medical Form

BEFORE YOU BEGIN — Please review the form first and be sure that you have all of the information you need before filling it out. You will NOT be able to save your work and return to this form at a later time.

When you have the information you need — fill out the Medication Record form below.

When the Medication Record form is completed and you’re ready — click SUBMIT.
IMPORTANT — Stay on this page until the form is done processing — otherwise, it may not go through. You will receive an email confirming LUM has received your form when it is submitted properly.

5th Quarter – Important Information, click HERE.
5th Quarter – main page, click HERE.

For a PDF version of the 5th Quarter Application & Medication Record Forms, click HERE.