67
20
Please fill out the form below.
*Required field
Download Card
first_name
First Name
input
First Name
true
Required.
last_name
Last Name
input
Last Name
true
Required.
date_of_birth
Date of Birth
date
true
Required.
gender
Gender
dropdown
Select Gender|Female:female|Male:male|Prefer not to say:prefernottoanswer
true
Required.
address_line_1
Address Line 1
input
Address Line 1
true
Required.
address_line_2
Address Line 2
input
Address Line 2
false
zip_code
Zip Code
input
Zip Code
true
Required.
Zip Code field must contain 5 numbers.
city
City
input
City
true
Required.
state
State
dropdown
Select State|Alabama: AL|Alaska: AK|Arizona: AZ|Arkansas: AR|California: CA|Colorado: CO|Connecticut: CT|Delaware: DE|District of Columbia: DC|Florida: FL|Georgia: GA|Guam: GU|Hawaii: HI|Idaho: ID|Illinois: IL|Indiana: IN|Iowa: IA|Kansas: KS|Kentucky: KY|Louisiana: LA|Maine: ME|Maryland: MD|Massachusetts: MA|Michigan: MI|Minnesota: MN|Mississippi: MS|Missouri: MO|Montana: MT|Nebraska: NE|Nevada: NV|New Hampshire: NH|New Jersey: NJ|New Mexico: NM|New York: NY|North Carolina: NC|North Dakota: ND|Ohio: OH|Oklahoma: OK|Oregon: OR|Pennsylvania: PA|Rhode Island: RI|South Carolina: SC|South Dakota: SD|Tennessee: TN|Texas: TX|Utah: UT|Vermont: VT|Virginia: VA|Washington: WA|West Virginia: WV|Wisconsin: WI|Wyoming: WY
true
Required.
email_address
Email Address
input
Email Address
true
Required.
Email Address* does not contain a valid email.
verify_email_address
Verify Email Address
input
Email Address
true
Required.
Verify Email Address* does not contain a valid email.
mobile_phone_number
Mobile Phone Number
input
Mobile Phone Number
false
Please enter your phone number
valid_prescriptions
I attest that I have valid prescriptions that match FDA-approved uses of my medications.
radio
true
Not eligible for REXULTI Savings Card
18_years
I attest that I am 18 years of age or older.
radio
true
Not eligible for REXULTI Savings Card
insured
I attest that I am insured by a commercial health plan and a resident of the United States or Puerto Rico.
radio
true
Not eligible for REXULTI Savings Card
terms_of_use_consent
checkbox
I understand that Otsuka America Pharmaceutical, Inc. (OAPI) or approved parties acting on its behalf may use the information I am providing to send me information and offers that may be of interest to me. OAPI will not sell or transfer my information to any unauthorized third parties. I understand that from time to time OAPI's privacy policy may change and that I should check OAPI's website for the most recent version of the Privacy Policy. I can request to stop receiving OAPI marketing communications by calling 1‑855‑REXULTI or by clicking the opt-out link below: https://www.REXULTI.com/us/unsubscribe.
By signing up to register and receive information, you confirm that you are 18 years or older.
- If you are the patient: you must be 18 or older to enroll yourself.
- If the patient is ages 13–17: an adult caregiver or family member (18+) must complete the enrollment on the patient’s behalf. The caregiver or family member also confirms that the patient is living with a condition for which REXULTI is indicated.
true
Not eligible for REXULTI Savings Card
xs
xs
62
md
sm
sm
62