Medical Rewards Network - Free Prescription Drug Card Program for Individuals

The Medical Rewards Network Prescription Discount Program is a free, fast and easy way to help you and your family save on the increasing cost of prescription drugs.

Enrollment in the prescription discount program is free with no monthly cost or obligation.

The Medical Rewards Network Free Prescription Card Discount Program includes an extensive participating pharmacy network that will provide you with discounted prescriptions drugs. Save up to 70% off the retail price of generic and brand name prescriptions.

Upon completion of the following form your application will be processed promptly and you will be mailed an ID card along with pharmacy network information. When prescriptions are needed, simply present your ID card to a network Pharmacy and begin saving.

Enroll children under 18 living in your household and other family members that you would like to receive a personalized card. All ID cards will be mailed to the address of the primary person on this application.

* fields are required:

*First Name:		Middle Initial:
*Last name:
*Email:
*Address:

*City:
*State:
*Zip:
Phone:
*Date Of Birth : mm/dd/yyyy		(Ex: 07/04/1976)
Spouse & Family Members under age 18 to be Enrolled and Listed on your ID Card:
Name:		Date Of Birth: mm/dd/yyyy
Name:		Date Of Birth: mm/dd/yyyy
Name:		Date Of Birth: mm/dd/yyyy
Name:		Date Of Birth: mm/dd/yyyy
Name:		Date Of Birth: mm/dd/yyyy
Name:		Date Of Birth: mm/dd/yyyy
Family/Household Members age 18 and older (Individual ID Cards will be issued)
Name:		Date Of Birth mm/dd/yyyy
Name:		Date Of Birth: mm/dd/yyyy
Name:		Date Of Birth: mm/dd/yyyy
Name:		Date Of Birth: mm/dd/yyyy
Additional Comments and Questions :	-- PUT YOUR MESSAGE HERE --