Simply complete this form to
receive your FREE prescription discount card.
First Name:
Last Name:
Email:
Phone:
Birth Date:
Mo.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Zip Code:
Gender:
Select
Male
Female
Do you have Health Insurance?
Yes
No
Special Offer!
Pick from 1000’s of magazines
& earn
$50
in Wal-Mart gift
card vouchers.
Yes
No
I agree to the terms and conditions
Fill out the form and print out your card now. It’s that easy.
Accepted at 85% of Pharmacies Nationwide, including: