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A seizure control medicine
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Special Savings Offer

Save up to $150 on your next 6 prescriptions of
LAMICTAL for epilepsy!


Sign up now to receive a savings card good for up to $25 off your out-of-pocket costs of your next 6 prescriptions of LAMICTAL for epilepsy. That's a total savings of up to $150! You'll also receive tips and information, like getting a restful night's sleep and balancing your life, so you can keep doing what you love.

This offer is only for US residents and is subject to eligibility requirements stated on the savings card.
Read Frequently Asked Questions about this special savings offer.


Please complete and submit the following form to receive FREE information and a savings card good for up to $25 off each of your next 6 prescriptions of LAMICTAL for epilepsy.
   Required Field
 First Name:
 Last Name:
 Address:
 City:
 State:
 ZIP Code:
E-mail Address:
 Date of Birth:
 Gender: Male Female



Are you signing up for:
Yourself
Someone else


Is the person you are signing up for:
A child under the age of 13 years
A child between the ages of 13 and 17 years
An adult over the age of 18 years


How long ago were you told by your child's healthcare provider that he/she should take medication for his/her seizures?
Less than 1 year ago
1-3 years ago
3-5 years ago
More than 5 years ago
He/she has not been diagnosed with epilepsy or a seizure disorder
He/she has not been told by a healthcare provider that he/she needs to take      medication for seizures.


Is he/she currently taking LAMICTAL?
Yes
No
Don't Know


How long ago were you told by your healthcare provider that you should take medication for your seizures?
Less than 1 year ago
1-3 years ago
3-5 years ago
More than 5 years ago
I have not been diagnosed with epilepsy or a seizure disorder
I have not been told by my healthcare provider that I need to take medication      for my seizures.


Which of the following prescription medication(s) are you currently taking? (Please check all that apply.)
CARBATROL®* (carbamazepine)
DEPAKENE®*/DEPAKOTE®* (valproic acid; divalproex sodium)
DILANTIN®* (phenytoin)
GABITRIL®* (tiagabine HCI)
KEPPRA®* (levetiracetam)
LAMICTAL®* (lamotrigine)
LYRICA®* (pregabalin)
MYSOLINE®* (primidone)
NEURONTIN®* (gabapentin)
PHENYTEK®* (extended phenytoin sodium)
TEGRETOL®* (carbamazepine)
TOPAMAX®* (topiramate)
TRILEPTAL®* (oxcarbazepine)
ZONEGRAN®* (zonisamide)
You are not currently taking any of these prescription medications

Which of the following prescription medications is your child taking? (Please check all that apply.)
CARBATROL®* (carbamazepine)
DEPAKENE®*/DEPAKOTE®* (valproic acid; divalproex sodium)
DILANTIN®* (phenytoin)
GABITRIL®* (tiagabine HCI)
KEPPRA®* (levetiracetam)
LAMICTAL®* (lamotrigine)
LYRICA®* (pregabalin)
MYSOLINE®* (primidone)
NEURONTIN®* (gabapentin)
PHENYTEK®* (extended phenytoin sodium)
TEGRETOL®* (carbamazepine)
TOPAMAX®* (topiramate)
TRILEPTAL®* (oxcarbazepine)
ZONEGRAN®* (zonisamide)
Your child is not currently taking any of these prescription medications

How long have you been taking LAMICTAL?
Less than 1 year
1-3 years
3-5 years
More than 5 years


How long has your child been taking LAMICTAL?
Less than 1 year
1-3 years
3-5 years
More than 5 years


Would you like to receive information, including treatment options, about any of the following health concerns?
Anxiety
Asthma
COPD/Chronic Bronchitis
Erectile Dysfunction
Heart Disease
High Blood Pressure
Migraine
Nasal Allergies
Prostate Cancer
None



By providing your name, address, e-mail address, and other information, you are giving GlaxoSmithKline (GSK) and companies working with GSK permission to market or advertise to you regarding the medical condition(s) in which you've expressed an interest, as well as other general health related information from GSK. GlaxoSmithKline will not sell or transfer your name, address, or e-mail address to any other party for their own marketing use.

For additional information on how GSK handles your information, please read our privacy statement.



*LAMICTAL is a registered trademark of The GlaxoSmithKline Group of Companies. All other brands listed are trademarks of their respective owners and are not trademarks of The GlaxoSmithKline Group of Companies. The makers of these brands are not affiliated with and do not endorse GlaxoSmithKline or its products.