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Patient Referral Form

Thank you for choosing Beck's!

As a new customer to Beck’s Drugs & Home Healthcare Products, Inc, you are entitled to $20 off any new or transferred prescription & non-prescription. This offer is good with any new or transferred prescription, or major medical equipment purchase/rental.

Please fill out the form below and we will get in touch with you about redeeming your discount. You may also print out this form, fill it out and bring it into the store.

What is a new customer?
A new customer is a first time customer or a customer who has been non-active for over a year.

  • New Customer Name
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  • New Customer Address
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  • *     
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  • Existing Referring Customer Name
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  • *

 

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