Post on 03-Apr-2018
SAVEUP TO
- OR -
50%OFF
FreshKote® AND TOZAL®
FLM007-0417-02
Patient Name ____________________________ Age ___________
Date ___________________________________________________
Doctor Name ___________________________________________
License # _______________________________________________
Address ________________________________________________
City __________________ State ______ Zip ___________________
Phone _________________________________________________
Label
Re�ll __________ Times
Signature _______________________________________________
FreshKote®
TOZAL®
To Patient: Obtain your member ID at FOCUScoupon.com or by calling 1-866-752-6006.
Take this form to your pharmacist and receive up to 50% off your purchase of FreshKote® and/or TOZAL®. Member ID and recommendation required to redeem savings.
If you have any questions pertaining to the use of this card, please call 1-866-752-6006.
To Pharmacist: Submit a PRIMARY claim to PDMusing BIN: 610020. This card is valid for prescription and over the counter use.
For processing questions, please call 1-866-752-6006.Monday - Friday, 8 AM - 7 PM CST
Eligibility Restrictions: Void where taxed, restricted, or prohibited by law. FOCUS Laboratories, Inc., has the right to cancel this offer, or to change the rules of the program, without notice.
© 2017 FOCUS Laboratories, Inc. All Rights Reserved.
MEMBER ID:
BIN: 610020 GROUP: 99992239
Register for yourSavings Member ID atFOCUScoupon.com