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NiceRx waiting list capture
1
How much do you spend per month on your medications?
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Less than $100 per month
Between $100 to $500 per month
Between $500 to $1000 per month
More than $1000 per month
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2
What is your annual household income?
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Less than $25,000 per year
Between $25,000 to $50,000 per year
Between $50,000 to $75,000 per year
More than $75,000 per year
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3
Which brand name medications do you need help with?
Please enter all brand name medications you are taking.
Separate each medication by comma (e.g. ozempic, januvia)
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4
Please provide us with your contact information:
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First name
Last name
Phone number
Email
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5
By submitting my information, I agree to receive information and offers from NiceRx and its partners.
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