Old Town Rewards Signup

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Old Town Rewards | $20 Saves You 20% |

20% Off All Cash Prescriptions!*

20% Off All Front End Retail and Special Order Items!*

Free Monthly Weight-Loss Consultation!

Free Unlimited Prescription Deliveries!

Free Medication Compliance Packaging Regardless of Prescription Count!

Free enrollment in the Retail My Meds Program!*

Personalized Medication Review and Consultation with a Clinical Pharmacist, $190.00 value!*

Discounted Clinical & Testing Services!

Free Standard Dose Flu Vaccination!*

*Discount does not apply to prescriptions submitted to insurance and does not reduce any patient copay requirements. Prescriptions must be paid for through the Old Town Plan. Discount not valid in combination with any other discounts, coupons, or promotions. Enrollment in Retail My Meds is voluntary and optional. Additional forms required. Please request information from an Old Town Pharmacy employee. Limit of one medication review and clinical consulation per year per patient. Medication review is for entire medication list and interactions, limit shall not prevent patient from recieving standard pharmacist consultation regarding the proper use of dispensed prescriptions. Flu vaccination is limited to the standard dose flu vaccine or booster shot and does not include high dose flu vaccination. Flu vaccine limit of one dose per patient per year. 20% discount applied to all subsequent vaccination paid in cash.

Please Bill Me Each Month for :

Old Town Rewards ($20.00)

Subscription Billing Authorization:

By submitting this form you are agreeing to this subscription and authorize Old Town Pharmacy, LLC to charge the payment method you have on file for the recurring subscription fees. You understand and agree that this authorization will remain in effect until you cnacel your subscription. Your billing information is not kept on Old Town Pharmacy computers or servers and will be securely maintained by our payments processor. Payment will be collected between the first and fifth day of each month you are enrolled in the subscription services. Old Town Pharmacy's standard patient privacy policy applies to all information collected through this form or programs you participate in with the pharmacy. The subscription period is for one year and will autimatically renew unless you provide notice of cancellation to pharmacy management. Subscription services and programs are non-refundable once billed, please be sure of your subscription selection prior to submitting this form.

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