clubcette™ registration
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Please complete the form below, in order to receive up to $10 off of your next 2 Mircette® refills when you use your ClubCette™ Savings Card.* We appreciate your interest in ClubCette™ and you will receive registration confirmation via email shortly. To learn more about Mircette®, speak to your doctor or healthcare provider. |
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Required Fields |
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First Name: |
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Last Name: |
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Email Address: |
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Address: |
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Address 2: |
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Savings Card #: |
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City: |
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State: |
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Zip: |
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Country: |
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Date of birth: |
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Product: |
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How many refills do you have left on your prescription?
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Are you enrolled in any government, state, or federally funded medical or prescription benefit program? This includes Medicare, Medicaid, Medigap, VA, DOD, and TriCare as well as any other state or federal employee benefit programs.
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Savings offer is not valid for prescriptions purchased under Medicaid, Medicare, or similar federal, state, or other government funded benefit programs. Should you begin receiving assistance from a federal, state, or government funded program at any time, you will no longer be eligible to participate in this program. We may contact you by phone or mail periodically in order to verify that your eligibility for the program has not changed. Do you acknowledge your agreement with this statement?
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Last 4 digits of your phone number: |
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| * Offer valid on a Mircette® prescription or generic equivalent. |
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Mircette® and Duramed® are registered trademarks of Duramed Pharmaceuticals, Inc.
ClubCette™ is a trademark of Duramed Pharmaceuticals, Inc.
Duramed is a subsidiary of Barr Pharmaceuticals, Inc.
The site is intended for residents of the United States only.
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