Receive up to

Mail-in Rebate* Offer
Receive up to
25
$
off your prescription of
) 400 capsules
mg
fenoprofen calcium
NALFON (200mg
and capsules
400mg
Good for 1 prescription of 30 or more capsules of Nalfon
Offer valid until 12/31/11
*This rebate offer is brought to you by WraSer Pharmaceuticals.
To receive a rebate on your out-of-pocket expenses, up to $25 for NALFON, complete the back section of this rebate form. Include your original pharmacy receipt
showing your name, pharmacy name, and your purchase of NALFON, along with
this form and mail to the address given on the back. NALFON (fenoprofen calcium)
capsules are available only with a prescription. Offer is valid if prescribed before
12/31/11 and received by 12/31/11.
Nalfon® is a registered trademark of Pedinol Pharmacal, Inc.
(fenoprofen calcium capsules) 400 mg
By fully completing this form, you will be eligible to receive a rebate
equal to the amount of your out-of-pocket expenses, up to $25, on
the retail purchase of your prescription for NALFON capsules*,
subject to the terms and conditions below.
Please be sure to:
• Fill your prescription of NALFON.
• Clearly print your name and address and sign this rebate form.
• Enclose the original pharmacy receipt showing NALFON, your
name and pharmacy name.
• Enclose the cash register receipt. Circle the amount paid.
• Mail to: NALFON Rebate Offer
121 Marketridge Rd.
Ridgeland, MS 39157
Please Print Clearly:
Name __________________________ Date of Birth _____________
Address _________________________________________________
City _____________________ State __________ Zip _____________
Your Physician's Name:_____________________________________
Your Signature:___________________________________________
*Offer expires 12/31/11. Please allow for 6 to 8 weeks for receipt of rebate. Offer good only in the USA. This
offer is not valid for prescriptions eligible to be reimbursed, in whole or in part, by Medicare (including Medicare
Part D), Medicaid, CHAMPUS, or the Department of Veterans Affairs, or any other similar federal or state programs (including any state prescription drug assistance programs). Offer is not valid for prescriptions eligible
to be reimbursed by any private indemnity or HMO plan or other health or pharmacy benefit program that reimburses you for the entire cost of your prescription drugs. Offer is not valid for residents of Massachusetts whose
prescriptions costs are paid all or in part by any insurer or other third-party payer, or where otherwise prohibited,
taxed or restricted by law. This rebate is limited to $25 on NALFON® or your co-payment - whichever is less. You
are responsible for reporting your receipt of this rebate to any private insurer that pays for or reimburses you for
part or all of the prescription filled. No group or organization requests will be honored. Original pharmacy receipt
must be included, and will not be returned. This form may not be reproduced and must accompany your request.
Duplicate refund requests will not be accepted. WraSer Pharmaceuticals reserves the right to rescind, revoke,
or amend this offer without notice.
I understand and agree to comply with the terms and conditions of this offer, as set forth above.
_______________________________________________________________________________________________
(Patient’s signature required)
© 2011 WraSer Pharmaceuticals
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