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Important Safety Information
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Side effects with Allegra-D 12 Hour and Allegra-D 24 Hour were similar to Allegra® 60 mg alone (headache, insomnia or nausea) and Allegra 180 mg alone (headache, cold or backache) respectively. Due to the decongestant (pseudoephedrine) component in both Allegra-D 12 Hour and Allegra-D 24 Hour, these products must not be used if you: are taking an MAO inhibitor (a medication for depression) or have stopped taking an MAO inhibitor within 14 days; retain urine; have narrow-angle glaucoma; have severe high blood pressure or severe heart disease. Side effects with pseudoephedrine may include nervousness, restlessness, dizziness, or insomnia. Headache, drowsiness, increased heart rate, palpitations, increased blood pressure, and abnormal heart rhythms have been reported. You should also tell your doctor if you have high blood pressure, diabetes, heart disease, glaucoma, thyroid disease, impaired kidney function, or symptoms of an enlarged prostate such as difficulty urinating. Click here for additional important information for Allegra-D 24 Hour and Allegra-D 12 Hour *Rebate offer is for up to $24 per prescription off your out-of-pocket payment when you purchase Allegra-D 24 Hour or Allegra-D 12 Hour and send in rebate certificate with original pharmacy receipt. Offer not valid for prescriptions reimbursed or paid under Medicare, Medicaid, or any similar federal or state health care program, including any state medical or pharmaceutical assistance programs. Void in Massachusetts if any insurer or other third-party payer reimburses you or pays for any part of the prescription price. Offer also void where prohibited by law, taxed, or restricted. Amount of rebate for the purchase of Allegra-D 24 Hour or Allegra-D 12 Hour will not exceed $24 or amount of copay, whichever is less. This certificate may not be reproduced and must accompany your request. Offer good only for prescription of Allegra-D 24 Hour & Allegra-D 12 Hour and only in the USA. Offer expires 10/31/09. Sanofi-aventis U.S. reserves the right to rescind, revoke, or amend this offer without notice. You are responsible for reporting receipt of a rebate to any private insurer that pays for or reimburses you for any part of the prescription filled. Limit of 12 rebates annually (up to $288). |
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Yes! I would like to receive additional information regarding allergies and
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Out of the 365 days in a year, how many days do you take medication for your seasonal allergies? | |||||
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0-30 days (1 mo) |
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121-180 days (6 mos) | ||
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31-60 days (2 mos) |
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181-240 days (8 mos) | |||
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61-90 days (3 mos) |
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241-300 days (10 mos) | |||
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91-120 days (4 mos) |
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301-365 days (year-round) |
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Which medications are you currently taking for your allergies?* (check all that apply) | |||||
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Alavert® |
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Sudafed® | ||
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Benadry® |
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Sudafed® Sinus & Allery | |||
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Benadryl-D® |
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Tylenol® Allergy/Sinus | |||
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Claritin® |
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Tylenol® Severe Allergy | |||
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Claritin-D® |
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Zyrtec® | |||
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Clarinex® |
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Zyrtec-D® | |||
| *Trademarks listed are those of their respective owners and not of sanofi-aventis U.S. |
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How many prescription antihistamines or antihistamine/decongestants have you purchased in last 12 months? | |||||
Please sign here to certify that you understand, accept, and are complying with all the requirements and restrictions listed on this form. This also certifies that redeeming this certificate is consistent with the requirements of your health plan.
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© 2009 sanofi-aventis U.S. LLC
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