GoodRx Opt-Out Form
We apologize for any inconvenience that this may have caused you. To ensure that we place the correct information onto our DO NOT MAIL list, please fill out this short form with the information from the shipping label on the box.
Provider NPI (do not fill out unless provided with NPI)
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Provider Title (i.e. Dr., Mr. Mrs., etc)
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Provider First Name
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Middle Name/Initial (if provided)
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Provider Last Name
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Organization/Company
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Address *
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City *
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State *
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Zip *
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Why are you opting out of receiving GoodRx kits? (check all that apply)
Please provide us with any additional feedback or comments that you feel is necessary.
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