PATIENT INFORMATION
First Name: 
Last Name:
Address:
City:
State:
Zip Code:
Date Of Birth: (mm/dd/yyyy)
Sex:  Male    Female
Phone: (###) ###-#### 
Email Address:
Are you a NEW Fred's Pharmacy Customer?  Yes  No
How did you hear about the Prescription Plus program? 

Patient Authorization

This program is administered by National Pharmaceutical Network, Inc. (“NPN”). The program offers the cardholder preferred pricing on select prescription medications (designated by NPN from time to time) at participating pharmacy locations. Cardholder must use the card at the time of purchase. By using this card, you acknowledge and agree that NPN and participating pharmacies (i) may have access to your medication data and use it for administration of this program and (ii) may mail you general information, from time to time. NPN and participating pharmacies will comply with all applicable privacy laws, except such information may be shared with affiliates of participating pharmacies and NPN. NPN, participating pharmacies, or affiliates will not release any personal information to outside entities for any purpose other than outlined above. This Program does not confer any rights upon the cardholder and this program and any discounts may be amended, or discontinued at any time by NPN without notice to cardholder. NPN may adopt rules to administer the Program. Neither NPN nor participating pharmacies shall have any liability with respect to this Program or the issuance of the cards. Notwithstanding the foregoing, in no event shall NPN's liability exceed any amounts paid to NPN by or for the benefit of Cardholder. This program shall be governed by the laws of the State of Tennessee, and venue for any action brought with respect hereto  shall be brought solely in a competent court of located in Shelby County, Tennessee. Enrollment Fees are waived for the 2008 calendar year. Thereafter, NPN may charge an annual fee to Cardholder which shall not exceed $25.00.  Cardholder shall have the right to cancel his/her participation in the Program at any time by providing written notice to NPN. All cards remain the property of NPN.

If you agree to the above statement, we simply need two additional items from you in lieu of your signature, authorizing National Pharmaceutical Network, Inc. to enroll you into Prescription Plus Program. 
Mother's Maiden Name:
We would like to share this exciting program with your co-workers, friends, and family members.  Please provide us with the contact information for your employer or non-profit organization, such as your church or charitable organization, so that we can extend the benefits to them!

ADDITIONAL INFORMATION (Optional)

Employer or Non-Profit Organization:   
Group  
Address:   
City:   
State:   
Zip Code:   
Phone: (###) ###-####   
Email Address:   
How many individuals in this group?