<%@ Language=JavaScript %> <%@ Language=JavaScript %> Receive Infomation on NHCD's Dicount Plans
NHCD
National Health Care Discount
"We Save You Money!"

We would like to welcome you to our

 growing family of satisfied customers!

Please fill out the information requested below and click on the Confirm Button.
We will contact you shortly to answer any questions and/or give more details.

Note that an asterisk ( * ) indicates a required field.

We take your privacy very seriously.

Your information will be kept strictly confidential and never shared.

Request Information Form

First Name:*

Last Name:*

Telephone No:*

 []- -

State:*

City:

E-Mail:

Household Members:

   


Request Information For:*

     Dental            RX             Vision


Best Time To Contact:*

     Morning       Afternoon     Evening
   


Please list some of the current medications within the household, including name, strength, quantity, and current price paid.  Our representative will have a no obligation quote ready for you.


Optional:

Optional: (any other information you would like to provide, comments, questions, etc.)


 
Due to technical difficulties with tripod, this page may not be sending properly. To ensure that we receive your application please copy and paste this page once completed into an email and send it to the Info@NHCD email link at the bottom of this page. Simply click Info@NHCD and you will be taken to your email. Thanks for your cooperation and we look forward to hearing from you!
If you would like immediate information regarding our plans, feel free to contact Janet Horne, Sales Associate, toll-free (866)437-2580 between 8:00 AM to 5:00 PM Mountain Time, Monday - Saturday.

Do you have any questions or comments regarding NHCD?
Click here to email us Info@NHCD