Discount Card Information:
Group Code:
Name to appear on Card:
Phone Number:

Order Quantity:
English Cards:

Spanish Cards:

Script Pads:

Card Holders:


Shipping Information

For Other Amounts Please Explain Below

Shipping Included!
$30.00 shipping surcharge for customers outside of continental U.S.

Ship To:
Residential Address
Business Address
Please Explain Below
Ship To Name:
Shipping Address 1:
Shipping Address 2:
Zip Code:

Billing Information:

Your credit card will be processed through our holding company Maffett's Advertising, LLC.

Card Type:

Card Number:
Expiration Date:
Security Code:
Name on Card:
Billing Address 1:
Billing Address 2:
Zip Code:


e-mail address

The following form is use to order the InCareRx Prescription Discount Cards.
Please Fill it Out Completely.
Press the "Submit" button to send us the information.
Before Submitting The form You may press the "Print Form" button to keep a copy for your records.

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