Lost Customer

E-Comm Sign Up

<link href="//cdn-images.mailchimp.com/embedcode/classic-071822.css" rel="stylesheet" type="text/css">
<style type="text/css">
	#mc_embed_signup{background:#fff; clear:left; font:14px Helvetica,Arial,sans-serif;  width:600px;}
	/* Add your own Mailchimp form style overrides in your site stylesheet or in this style block.
	   We recommend moving this block and the preceding CSS link to the HEAD of your HTML file. */
</style>
<div id="mc_embed_signup">
    <form action="https://marleydrug.us5.list-manage.com/subscribe/post?u=5989b745d85b6ec1c805573ca&amp;id=f37b8f0224&amp;f_id=002d65e9f0" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate>
        <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>
</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[6]='MMERGE6';ftypes[6]='date';fnames[5]='MMERGE5';ftypes[5]='text';}(jQuery));var $mcj = jQuery.noConflict(true);</script>

Pharmacy Hours

Contact us

Follow us