One Price Prescription Drug Program

Note: Red indicates a required field.

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Primary Member Name:

Address:

City:

State:

Zip:

Phone Number: (ie. 123-456-7890)

Date of Birth: (ie. MM/DD/YYYY)

Employer:

Referral Code: (If Applicable)

Please List All Other Eligible Household Members
Name	Date of Birth	Relationship
1.	(ie. MM/DD/YYYY)
2.	(ie. MM/DD/YYYY)
3.	(ie. MM/DD/YYYY)
4.	(ie. MM/DD/YYYY)
5.	(ie. MM/DD/YYYY)

Primary Member's Email Address: (ie. you@domain.com)
We respect your email privacy and promise never to share or rent your personal information to any unauthorized thrid party.

Inform me of relevant and timely health information and alerts.

We are committed to keeping you informed on heath related issues and as a member of the 1-Price Prescription Plan you will receive for free, our monthly newsletter, Healthy Home News. We will also keep you informed via email about drug recalls, alerts and health news to insure your safety and good health. Email is our only method of communication with large groups of members in a timely manner. If you have any particular areas of concern that you would like to receive updated information on, please indicate below by checking ALL topics of interest or concern.

Allergies	Asthma	Arthritis	Anxiety
Cholesterol	Depression	Diabetes	Heart Disease
Hypertension	Natural Remedies	Nutrition	Pain Management
Mental Health	Men's Health	Veterinary	Children's Health
Sleep Disorders	Weight Loss	Smoking Cessation	Women's Health

One Price Prescription Drug Program

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