Script Your Future Pledge

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Join our movement. Take a shot. Pledge with us!

By filling out this form, you pledge to take your medications as directed and to receive the COVID-19 vaccine.

Please fill out this form by April 2, 2021 to be entered into a raffle for a $10 Amazon gift card. Thank you!

AMCP Health Helper

First and Last Name? *

Email Address? *

I pledge to take my medications as directed by my healthcare provider. *

Yes

I am not taking any medications.

I pledge to get the COVID-19 vaccine. *

Yes

I received my first dose of the COVID-19 vaccine and will receive my second dose.

I received both doses of the COVID-19 vaccine already.

Any questions or comments? Thank you for your time and stay safe! Make sure to visit our website at http://tinyurl.com/medication-adherence for more resources.

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