E-Comm Email Sign Up

Zypitamag 30 Day Free

<link href="//cdn-images.mailchimp.com/embedcode/classic-071822.css" rel="stylesheet" type="text/css">
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    <form action="https://marleydrug.us5.list-manage.com/subscribe/post?u=5989b745d85b6ec1c805573ca&amp;id=96834d5d25&amp;f_id=00e166e9f0" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate>
        <div id="mc_embed_signup_scroll">
        <h2>Sign Up ED Customer</h2><br><p> They will receive 1 email/month on the first Tuesday of every month with a new coupon.<br> Sign up is required for them to use an ED coupon.</p>
        <div class="indicates-required"><span class="asterisk">*</span> indicates required</div>
<div class="mc-field-group">
	<label for="mce-EMAIL">Email Address  <span class="asterisk">*</span>
</label>
	<input type="email" value="" name="EMAIL" class="required email" id="mce-EMAIL" required>
	<span id="mce-EMAIL-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group size1of2">
	<label for="mce-MMERGE8">ID # </label>
	<input type="number" name="MMERGE8" class="" value="" id="mce-MMERGE8">
	<span id="mce-MMERGE8-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group">
	<label for="mce-FNAME">First Name  <span class="asterisk">*</span>
</label>
	<input type="text" value="" name="FNAME" class="required" id="mce-FNAME" required>
	<span id="mce-FNAME-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group">
	<label for="mce-LNAME">Last Name  <span class="asterisk">*</span>
</label>
	<input type="text" value="" name="LNAME" class="required" id="mce-LNAME" required>
	<span id="mce-LNAME-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group size1of2">
	<label for="mce-PHONE">Phone Number </label>
	<input type="text" name="PHONE" class="" value="" id="mce-PHONE">
	<span id="mce-PHONE-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group size1of2">
	<label for="mce-MMERGE7-month">Day of Birth  <span class="asterisk">*</span>
</label>
	<div class="datefield">
		<span class="subfield monthfield">
			<input class="datepart required" type="text" pattern="[0-9]*" value="" placeholder="MM" size="2" maxlength="2" name="MMERGE7[month]" id="mce-MMERGE7-month" required>
		</span> / 
		<span class="subfield dayfield">
			<input class="datepart required" type="text" pattern="[0-9]*" value="" placeholder="DD" size="2" maxlength="2" name="MMERGE7[day]" id="mce-MMERGE7-day" required>
		</span> / 
		<span class="subfield yearfield">
			<input class="datepart required" type="text" pattern="[0-9]*" value="" placeholder="YYYY" size="4" maxlength="4" name="MMERGE7[year]" id="mce-MMERGE7-year" required>
		</span>
        <span class="small-meta nowrap">( mm / dd / yyyy )</span>
	</div>
	<span id="mce-MMERGE7-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group">
	<label for="mce-MMERGE6">Marley Drug Team Member </label>
	<input type="text" value="" name="MMERGE6" class="" id="mce-MMERGE6">
	<span id="mce-MMERGE6-HELPERTEXT" class="helper_text"></span>
</div>
<div hidden="true"><input type="hidden" name="tags" value="4071478"></div>
	<div id="mce-responses" class="clear">
		<div class="response" id="mce-error-response" style="display:none"></div>
		<div class="response" id="mce-success-response" style="display:none"></div>
	</div>    
    <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text" name="b_5989b745d85b6ec1c805573ca_96834d5d25" tabindex="-1" value=""></div>
    <div class="clear"><input type="submit" value="Subscribe" name="subscribe" id="mc-embedded-subscribe" class="button"></div>
    </div>
</form>
</div>
<script type='text/javascript' src='//s3.amazonaws.com/downloads.mailchimp.com/js/mc-validate.js'></script><script type='text/javascript'>(function($) {window.fnames = new Array(); window.ftypes = new Array();fnames[0]='EMAIL';ftypes[0]='email';fnames[1]='FNAME';ftypes[1]='text';fnames[2]='LNAME';ftypes[2]='text';fnames[3]='ADDRESS';ftypes[3]='address';fnames[4]='PHONE';ftypes[4]='phone';fnames[5]='MMERGE5';ftypes[5]='birthday';fnames[6]='MMERGE6';ftypes[6]='text';fnames[7]='MMERGE7';ftypes[7]='date';fnames[8]='MMERGE8';ftypes[8]='number';}(jQuery));var $mcj = jQuery.noConflict(true);</script>

<link href="//cdn-images.mailchimp.com/embedcode/classic-071822.css" rel="stylesheet" type="text/css">
<style type="text/css">
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    <form action="https://marleydrug.us5.list-manage.com/subscribe/post?u=5989b745d85b6ec1c805573ca&amp;id=388c5b9692&amp;f_id=001080e9f0" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate>
        <div id="mc_embed_signup_scroll">
       <h2>Sign Up for E-Comm Emails</h2><br><p>Customer will receive 3 emails in 1st month and 2 emails/month afterwards about Marley Drug, how to save money on medications, and various health tips. <br>The first email will be sent 24 hours after they are signed up.</p>
        <div class="indicates-required"><span class="asterisk">*</span> indicates required</div>
<div class="mc-field-group">
	<label for="mce-EMAIL">Email Address  <span class="asterisk">*</span>
</label>
	<input type="email" value="" name="EMAIL" class="required email" id="mce-EMAIL" required>
	<span id="mce-EMAIL-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group">
	<label for="mce-FNAME">First Name </label>
	<input type="text" value="" name="FNAME" class="" id="mce-FNAME">
	<span id="mce-FNAME-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group">
	<label for="mce-LNAME">Last Name </label>
	<input type="text" value="" name="LNAME" class="" id="mce-LNAME">
	<span id="mce-LNAME-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group size1of2">
	<label for="mce-PHONE">Phone Number </label>
	<input type="text" name="PHONE" class="" value="" id="mce-PHONE">
	<span id="mce-PHONE-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group size1of2">
	<label for="mce-BIRTHDAY-month">Birthday </label>
	<div class="datefield">
		<span class="subfield monthfield">
			<input class="birthday " type="text" pattern="[0-9]*" value="" placeholder="MM" size="2" maxlength="2" name="BIRTHDAY[month]" id="mce-BIRTHDAY-month">
		</span> / 
		<span class="subfield dayfield">
			<input class="birthday " type="text" pattern="[0-9]*" value="" placeholder="DD" size="2" maxlength="2" name="BIRTHDAY[day]" id="mce-BIRTHDAY-day">
		</span> 
		<span class="small-meta nowrap">( mm / dd )</span>
	</div>
	<span id="mce-BIRTHDAY-HELPERTEXT" class="helper_text"></span>
</div><div class="mc-field-group">
	<label for="mce-MMERGE6">Marley Drug Team Member </label>
	<input type="text" value="" name="MMERGE6" class="" id="mce-MMERGE6">
	<span id="mce-MMERGE6-HELPERTEXT" class="helper_text"></span>
</div>
<div hidden="true"><input type="hidden" name="tags" value="4034887"></div>
	<div id="mce-responses" class="clear">
		<div class="response" id="mce-error-response" style="display:none"></div>
		<div class="response" id="mce-success-response" style="display:none"></div>
	</div>    
    <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text" name="b_5989b745d85b6ec1c805573ca_388c5b9692" tabindex="-1" value=""></div>
    <div class="clear"><input type="submit" value="Subscribe" name="subscribe" id="mc-embedded-subscribe" class="button"></div>
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<script type='text/javascript' src='//s3.amazonaws.com/downloads.mailchimp.com/js/mc-validate.js'></script><script type='text/javascript'>(function($) {window.fnames = new Array(); window.ftypes = new Array();fnames[0]='EMAIL';ftypes[0]='email';fnames[1]='FNAME';ftypes[1]='text';fnames[2]='LNAME';ftypes[2]='text';fnames[3]='ADDRESS';ftypes[3]='address';fnames[4]='PHONE';ftypes[4]='phone';fnames[5]='BIRTHDAY';ftypes[5]='birthday';fnames[6]='MMERGE6';ftypes[6]='text';}(jQuery));var $mcj = jQuery.noConflict(true);</script>

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	#mc_embed_signup{background:#fff; clear:left; font:14px Helvetica,Arial,sans-serif;  width:600px;}
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	   We recommend moving this block and the preceding CSS link to the HEAD of your HTML file. */
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        <div id="mc_embed_signup_scroll">
        <h2>Zypitamag Sign Up Form - For Patients Who Get 30 Days Free</h2><br><p>Patients who get 30 days of Zypitamag free will get emails about what Zypitamag is and other health tips relates to Zypitamag</p>

        <div class="indicates-required"><span class="asterisk">*</span> indicates required</div>
<div class="mc-field-group">
	<label for="mce-EMAIL">Email Address  <span class="asterisk">*</span>
</label>
	<input type="email" value="" name="EMAIL" class="required email" id="mce-EMAIL" required>
	<span id="mce-EMAIL-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group">
	<label for="mce-FNAME">First Name  <span class="asterisk">*</span>
</label>
	<input type="text" value="" name="FNAME" class="required" id="mce-FNAME" required>
	<span id="mce-FNAME-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group">
	<label for="mce-LNAME">Last Name  <span class="asterisk">*</span>
</label>
	<input type="text" value="" name="LNAME" class="required" id="mce-LNAME" required>
	<span id="mce-LNAME-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group size1of2">
	<label for="mce-MMERGE6-month">Date of Birth  <span class="asterisk">*</span>
</label>
	<div class="datefield">
		<span class="subfield monthfield">
			<input class="datepart required" type="text" pattern="[0-9]*" value="" placeholder="MM" size="2" maxlength="2" name="MMERGE6[month]" id="mce-MMERGE6-month" required>
		</span> / 
		<span class="subfield dayfield">
			<input class="datepart required" type="text" pattern="[0-9]*" value="" placeholder="DD" size="2" maxlength="2" name="MMERGE6[day]" id="mce-MMERGE6-day" required>
		</span> / 
		<span class="subfield yearfield">
			<input class="datepart required" type="text" pattern="[0-9]*" value="" placeholder="YYYY" size="4" maxlength="4" name="MMERGE6[year]" id="mce-MMERGE6-year" required>
		</span>
        <span class="small-meta nowrap">( mm / dd / yyyy )</span>
	</div>
	<span id="mce-MMERGE6-HELPERTEXT" class="helper_text"></span>
</div>
<div class="mc-field-group">
	<label for="mce-MMERGE5">Marley Drug Team Member </label>
	<input type="text" value="" name="MMERGE5" class="" id="mce-MMERGE5">
	<span id="mce-MMERGE5-HELPERTEXT" class="helper_text"></span>
</div>
	<div id="mce-responses" class="clear">
		<div class="response" id="mce-error-response" style="display:none"></div>
		<div class="response" id="mce-success-response" style="display:none"></div>
	</div>    
    <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text" name="b_5989b745d85b6ec1c805573ca_f37b8f0224" tabindex="-1" value=""></div>
    <div class="clear"><input type="submit" value="Subscribe" name="subscribe" id="mc-embedded-subscribe" class="button"></div>
    </div>
</form>
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<script type='text/javascript' src='//s3.amazonaws.com/downloads.mailchimp.com/js/mc-validate.js'></script><script type='text/javascript'>(function($) {window.fnames = new Array(); window.ftypes = new Array();fnames[0]='EMAIL';ftypes[0]='email';fnames[1]='FNAME';ftypes[1]='text';fnames[2]='LNAME';ftypes[2]='text';fnames[3]='ADDRESS';ftypes[3]='address';fnames[4]='PHONE';ftypes[4]='phone';fnames[6]='MMERGE6';ftypes[6]='date';fnames[5]='MMERGE5';ftypes[5]='text';}(jQuery));var $mcj = jQuery.noConflict(true);</script>

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