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National Health Care Discount
Rx Application


Vitamins, Minerals, Herbs! | Rx Application | Contact Us
Please provide an answer below for each question.  If you qualify a representative will contact you to let you know what your discounts will be!

What is your first name?

What is your last name?

What is your telephone number?

Approximately how much does your household spend on medications each month?

Do you currently have Insurance or a discount card that covers part or all of your prescription medications (yes or no)?

If so, with whom?

What is one of your most expensive medications, or an illness you or someone in your household is being treated for?

Do You currently own a checking account and/or credit card?

What is the best time of day to reach you? AM, PM, Evenings, or Anytime?

Which Website or Classified Ad did you find this site located?

E-mail address?

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