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Pfizer Sulit Card Enrollment Form

This document is a membership form for the Pfizer Sulit Patient Care Program. It requests contact information from the applicant such as phone numbers and email. It also asks for a copy of a government ID and the applicant's doctor's details to match any prescriptions. By signing, the applicant agrees to the terms and conditions of Pfizer's patient care program to receive continued free membership benefits like using the Pfizer Sulit card.

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512 views1 page

Pfizer Sulit Card Enrollment Form

This document is a membership form for the Pfizer Sulit Patient Care Program. It requests contact information from the applicant such as phone numbers and email. It also asks for a copy of a government ID and the applicant's doctor's details to match any prescriptions. By signing, the applicant agrees to the terms and conditions of Pfizer's patient care program to receive continued free membership benefits like using the Pfizer Sulit card.

Uploaded by

jasfer
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Pfizer Sulit Card No.

This serves as your membership form to the Pfizer Sulit


Patient Care Program. Complete and sign the form and mail /
fax / email back for your continued FREE membership and
benefits like the usage of the Pfizer Sulit card.
Mail to: P.O Box 1139 Makati Central Post Office 1252 Makati City Philippines
Email: [email protected]
Fax: Metro Manila 672 2000
Provincial Toll free 1800 10 672 2000
Please attach 1 copy of any Government Issued ID

Contact Details:
Mobile Phone Number:
Home Phone Number:
Office Phone Number:
Email Address:
IMPORTANT: Your doctor’s details below should coincide with
your prescription:

By signing, I certify that the information given is true and correct. My enrollment
and / or use of the Sulit card shall be deemed my acceptance and agreement with
the terms and conditions of the Pfizer Sulit Patient Care Program as specified in
the enrollment form or Pfizer website.
PP-PCP-PHL-0031

Working together for a healthier world.

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