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To qualify for any of our FREE programs, we require that you fill out the following form.
We have 2 options for you. First, you can fill out the form using Microsoft Word©, save it, then email the document back to us. Or, you can print out the form, fill it out, then fax or bring it into the store. (If you are having problems filling out the form and emailing it, we recommend printing out the form and faxing or bringing it in.)
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Register for our FREE programs
PAPERLESS OPTION: This is a Word Document. Please fill it out and save it to your computer. When you are finished, please close the document, then reopen it to verify that your information has been saved. Finally, email it to us... that's it! |
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Register for our FREE programs
HARDCOPY OPTION: Please print this PDF and fill it out. You can fax it to us or bring it into our pharmacy. |
Our Current Free Programs
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