Order ADC Discount Cards Form

You may order a supply of cards using this form
to give to your patients, members or customers.

If you need a card or a few cards for personal or
family use, you may print one from the America's
Drug Card site by clicking here.

Name *

First

Last

Name of clinic, business, or group *

Email *

Phone number and best time to call *

Mailing street address or P.O. Box *

City, State, Zip code *

Number of cards to ship -- please consider a 3 months supply *

100 free cards 200 free cards 500 free cards 1000 free cards

Comment(s), questions or other helpful info *

Submit