(WAV) Enrollment Form

This form will not submit on-line. Please print out and bring in to either store or mail it in with your payment.

Name	Phone
Address	Date of Birth
City	SSN
Additional Family Member	Date of Birth
Additional Family Member	Date of Birth
Additional Family Member	Date of Birth
Additional Family Member	Date of Birth
Additional Family Member	Date of Birth
Additional Family Member	Date of Birth
Payment Method :(Check One) ____ Cash ____ Credit Card	__ Visa __ MasterCard __ Discover Card __ American Express
Card Number ______ ______ ______ ______	Credit Card Expiration Date___________

Preferred payment term

(Check One) ___ Monthly $7.95/month __ Semi-annual $39.75/6 months _ Annual $72.00/ year

I authorize Webb's Family Pharmacy to charge my credit card for the membership term stated above and I understand that this program will automatically renew unless canceled by me.

Signature: X

WAV

Savings on Prescriptions and more…

Enroll today, the savings will start immediately.

ü Guaranteed Acceptance

ü No Age Limits

ü No Mail Order

ü No Deductibles

ü You control your private medical history

Ø Sign up today by completing the this enrollment form, choose your payment options and pay enrollment fee.

Ø Our pharmacist will validate your ID card and enter the information into our computer system.

Ø The computer will calculate your WAV discount price each time you get a prescription filled.

Ø Covered services include medications requiring a physician’s written prescription.

Ø Your savings will vary based on the item. In most cases you will save approximately 10% off our everyday low price. You may save even more on certain items.

“Wav Goodbye to High Prices!”

Located in Rochester and Akron Indiana

“The Professional Pharmacy with the Hometown Touch...”

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