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SAVE UP TO - OR - 50 % OFF FreshKote ® AND TOZAL ® FLM007-0417-02 Patient Name ____________________________ Age ___________ Date ___________________________________________________ Doctor Name ___________________________________________ License # _______________________________________________ Address ________________________________________________ City __________________ State ______ Zip ___________________ Phone _________________________________________________ Label Refill __________ Times Signature _______________________________________________ FreshKote ® TOZAL ® To Patient: Obtain your member ID at FOCUScoupon.com or by calling 1-866-752-6006. Take this form to your pharmacist and receive up to 50% off your purchase of FreshKote ® and/or TOZAL ® . Member ID and recommendation required to redeem savings. If you have any questions pertaining to the use of this card, please call 1-866-752-6006. To Pharmacist: Submit a PRIMARY claim to PDM using BIN: 610020. This card is valid for prescription and over the counter use. For processing questions, please call 1-866-752-6006. Monday - Friday, 8 AM - 7 PM CST Eligibility Restrictions: Void where taxed, restricted, or prohibited by law. FOCUS Laboratories, Inc., has the right to cancel this offer, or to change the rules of the program, without notice. © 2017 FOCUS Laboratories, Inc. All Rights Reserved. MEMBER ID: BIN: 610020 GROUP: 99992239 Register for your Savings Member ID at FOCUScoupon.com

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SAVEUP TO

- OR -

50%OFF

FreshKote® AND TOZAL®

FLM007-0417-02

Patient Name ____________________________ Age ___________

Date ___________________________________________________

Doctor Name ___________________________________________

License # _______________________________________________

Address ________________________________________________

City __________________ State ______ Zip ___________________

Phone _________________________________________________

Label

Re�ll __________ Times

Signature _______________________________________________

FreshKote®

TOZAL®

To Patient: Obtain your member ID at FOCUScoupon.com or by calling 1-866-752-6006.

Take this form to your pharmacist and receive up to 50% off your purchase of FreshKote® and/or TOZAL®. Member ID and recommendation required to redeem savings.

If you have any questions pertaining to the use of this card, please call 1-866-752-6006.

To Pharmacist: Submit a PRIMARY claim to PDMusing BIN: 610020. This card is valid for prescription and over the counter use.

For processing questions, please call 1-866-752-6006.Monday - Friday, 8 AM - 7 PM CST

Eligibility Restrictions: Void where taxed, restricted, or prohibited by law. FOCUS Laboratories, Inc., has the right to cancel this offer, or to change the rules of the program, without notice.

© 2017 FOCUS Laboratories, Inc. All Rights Reserved.

MEMBER ID:

BIN: 610020 GROUP: 99992239

Register for yourSavings Member ID atFOCUScoupon.com