| APPLICATION FORM |
|
| NOTE: Your card will be sent to you by mail. |
| |
|
| Please fill out all form fields marked with * |
| |
|
| Title: * |
|
| Surname: * |
|
| First Names In Full * |
|
| I.D Number Or Passport Number * |
|
| Date of Birth (year / mnth / day) * |
|
Marital Status: *
|
|
Sex: *
|
|
| |
|
| Your Contact Details |
|
| |
|
| Work Tel No: * |
|
| Home Tel No: |
|
| Cell Number: * |
|
| Email Address: * |
|
| Postal Address: * |
|
| Code * |
|
| Full Residential Address: * |
|
| Code * |
|
| Number of Dependants / Children: * |
|
| Occupation: * |
|
| Language: * |
|
| |
|
| Health and Wellness Interests which you would like information on: |
| |
|
|
Vitamins & Minerals |
|
Herbal & Homeopathic |
|
Nutraceuticals |
|
Sports Nutrition |
|
Slimming |
|
Tonics & Probiotics |
|
Women's Health |
|
Children's Health |
|
Beauty and Skin Care |
|
Diabetes |
|
AIDS / HIV |
|
Other |
| |
|
| |
Which Medical Aid do you belong to? * |
| |
|
| |
Do you exercise more than once a week? * |
| |
|
| |
|
| As a Health and Wellness card holder; we would like to update you on new product launches, product information, promotions and special events of interest to you ' as well as updating you on your point status. Please let us know the best way to do this: |
|
SMS
EMAIL
POST |
|
| |
|
| |
|
| |
|
| Terms & Conditions: |
|
| |
|
| 1.The Durbell Pharmacies' Health and Wellness Card is issued and remains the property of the Durbell Pharmacy Group, who reserves the right to decline, issue and withdraw the card at any time. |
| 2.Your Durbell Pharmacies' Health and Wellness Card must be present at the point of sale in order to qualify for rewards, otherwise the transaction cannot be recorded and therefore point cannot be given. Points cannot be claimed retrospectively. The card is not transferable. |
| 3.Every time you swipe your card, a percentage of your purchase amount, excluding prescriptions, will be allocated to your Health and Wellness Card in the form of redeemable points. |
| 4.Durbell Pharmacies reserve the right to alter the benefits of the program at any time. |
| 5.Durbell Pharmacies reserve the right to make certain products exempt from points. |
| 6.Points cannot be earned on scripts, although points earned on eligible products may be redeemed to pay for scripts. |
| 7.At least R20 must be spent in a single transaction to qualify for rewards. |
| 8.Your rewards cannot be exchanged for cash. They must be utilized as a discount on further in-store purchases. |
| 9.Should the card be misplaced, kindly contact your local Durbell Pharmacy to cancel and reissue. Identification must be resented. |
| |
|
| |
|
| Speak to our customer consultant in-store for more information or phone our Durbell Pharmacy Account Care Line on (021) 979-1600 |
| |
|
