Savings Program Registration

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[Hidden] Origin Name

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isPatient

Campaign Master Id (hidden)

STEP 1/2

Do you live in the United States, Puerto Rico, or Guam?

YES

Do you have commercial prescription drug insurance?

If you are enrolled in Medicare, Medicaid, or any other federal, state, or government-funded healthcare program, select "No".

YES

Have you read, and do you accept and agree to comply with, At Your Service Program Terms, Conditions, and Eligibility Criteria?

By activating this At Your Service Savings Offer, you certify that you are not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare, Medicaid, or any private indemnity or HMO insurance plan that reimburses you for the entire cost of your prescription drugs. You also certify that you are not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. You further certify that should you begin receiving prescription benefits from one of these types of programs at any time, you will no longer participate in this savings program.

YES

STEP 2/2

FIRST NAME

LAST NAME

EMAIL ADDRESS

CELL PHONE NUMBER

(optional, to receive savings information on your phone)

By providing your email address above, you agree and acknowledge that you would like to receive email communications from AbbVie related to the At Your Service Savings Program and LUMIGAN^® 0.01%, ALPHAGAN^® P 0.1%, and COMBIGAN^®, including site updates, patient education, and reminders as well as other AbbVie products and services.

The information pertaining to you that we collect will be used in accordance with our Privacy Statement. If you later wish to stop receiving certain communications, you may unsubscribe by clicking on the link provided in any email. Privacy Policy on AbbVie.

Yes, I would like to receive other communications from Allergan, Inc., an AbbVie company. You can opt out of receiving emails at any time by clicking the unsubscribe link in any email.

By providing your mobile phone number, you agree and acknowledge that AbbVie may text you information about the At Your Service Savings Program and LUMIGAN 0.01%, ALPHAGAN P 0.1%, and COMBIGAN, including site updates, patient education, and reminders, as well as other AbbVie products and services, to your mobile device. I agree to the SMS Terms and Conditions , and understand that consent to texts is not required to sign up for this offer. You also understand that the frequency of these recurring messages depends on user preferences and activity and that message and data rates may apply. If you later wish to opt out from receiving this information, you understand that you can unsubscribe at any time by simply texting “STOP” to 72428 and receive help by texting “HELP” to 72428.

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I certify that the information I have provided about myself is complete and accurate.

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Please provide appropriate value in each field's default value property as per Analytics Tech Specs

Form Name:

Form Category:

Account Management, Contact, Interactions, Quiz, Registration, Services

Form Sub-Category:

Password Resets, Login, Profile, Representative, Contact Us, Polls, Social Share, Doctor Discussion Guide, Dosing Guide, Symptom Checker, Knowledge Assessment, Event, More Info, Sign Up, Saving Card, Benefit Verification, Benefit Enrollments, Medical Exception, Injection Form, Share a Story

Form MVA Name:

Form MVA Type:

Download, Form, Link, Share, Tool, Video

Form MVA Tier:

Form MVA Category:

Savings Card, Insurance, Symptom Journal, Test Score Tracker, Condition Information, Doctor Discussion Guide, Dosing Information, Enrollment Form, Flashcard, Medical Exception, Patient Counseling Guide, Savings Card, Symptom Journal, Doctor Discussion Guide, Doctor Search, Dosage Calculator, Enroll, Med Reminders, Quick Poll, Resource Request, Symptom Quiz, UGC Submission, Contact Rep, Savings Card, Social Share, App Store, More Info, Patient Resources, Share Information, Share Results, Submit a Story, Assessment Tool, Benefits Verification, Carousel, Initiation, Myth versus Fact, Workaround Quiz, Formulary Tool, Image Expand, Medical Exception, Q And A, Slider, Administration Instructions, Condition Information, Insurance, Inventory, Mechanism of Action, Patient Story, Product Overview, Program Overview, Injection Training, Other

Form PII Field Names for Masking:

Form Analytics Payload:

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