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27 28 29 <link rel="icon" type="image/x-icon" href="https://state-plan.unacdn.com/state_plan_images/favicons/new-mexico-favicon.ico" /> 30 </head> 31 32 <body> 33 <main class="container-full mt-28 flex"> 34 <div class="header new-mexico-header d-print-none"> 35 <div class="container"> 36 <a href="/"> 37 <img alt="New Mexico Drug Card - Statewide Assistance Program" class="logo-header img-fluid" src="https://state-plan.unacdn.com/state_plan_images/state-logos/new-mexico-logo.png" /> 38</a> </div> 39 40 <div class="nav-wrapper"> 41 <div class="container"> 42 <nav class="navbar navbar-expand-lg navbar-dark"> 43 <button class="navbar-toggler" type="button" data-bs-toggle="collapse" data-bs-target="#navbarNav" aria-controls="navbarNav" aria-expanded="false" aria-label="Toggle navigation"> 44 <span class="navbar-toggler-icon"></span> 45 </button> 46 <div class="collapse navbar-collapse flex-row-reverse flex-sm-column" id="navbarNav"> 47 <ul class="navbar-nav"> 48 <li class="nav-item dropdown"> 49 <a class="nav-link dropdown-toggle" href="#" id="navbarDropdown" role="button" data-toggle="dropdown"> 50 About 51 </a> 52 <div class="dropdown-menu" aria-labelledby="navbarDropdown"> 53 <a class="dropdown-item" href="/about">About New Mexico Drug Card</a> 54 <a class="dropdown-item" href="/partner-organizations">Partner Organizations</a> 55 </div> 56 </li> 57 <li class="nav-item dropdown"> 58 <a class="nav-link dropdown-toggle" href="#" id="navbarDropdown" role="button" data-toggle="dropdown"> 59 Get Card 60 </a> 61 <div class="dropdown-menu" aria-labelledby="navbarDropdown"> 62 <a class="dropdown-item" href="/create">Free Rx Savings Card</a> 63 <a class="dropdown-item" href="/order-bulk-cards">Customize and Order Bulk Cards</a> 64 </div> 65 </li> 66 <li class="nav-item"> 67 <a class="nav-link" href="/medication-pricing">Medication Pricing</a> 68 </li> 69 <li class="nav-item"> 70 <a class="nav-link" href="/media">Media Center</a> 71 </li> 72 <li class="nav-item dropdown d-none"> 73 <a class="nav-link dropdown-toggle" href="#" id="navbarDropdown" role="button" data-toggle="dropdown"> 74 Resources 75 </a> 76 <div class="dropdown-menu" aria-labelledby="navbarDropdown"> 77 <a class="dropdown-item d-none" href="/pharmacy-locator">Pharmacy Locator</a> 78 </div> 79 </li> 80 <li class="nav-item"> 81 <a class="nav-link" href="/pharmacies">Pharmacies</a> 82 </li> 83 <li class="nav-item"> 84 <a class="nav-link" href="/contact">Contact</a> 85 </li> 86 <li class="nav-item social-btn"> 87 <a target="_blank" href="http://www.facebook.com/newmexicodrugcard"> 88 <img src="/assets/facebook-button-107e47ab48e019090611569b9034b0db0687641bc50d3773a376d5aacd56bb19.png" /> 89</a> <a target="_blank" href="http://twitter.com/NMDrugCard"> 90 <img src="/assets/twitter-button-c18e041e2c208061a7e90116c9d30d3e6127e60b7200983189f0bc072aa1294f.png" /> 91</a> </li> 92 </ul> 93 </div> 94 </nav> 95 </div> 96 </div> 97</div> 98 99 100 101 102<div class="container content-wrapper"> 103 <div class="row px-lg-4"> 104 <div class="col-lg-12 main-content"> 105 <h1 class="text-center">Contact Us</h1> 106 <p class="text-center"><strong>Have questions or comments?</strong> Please fill out the form below and we will respond as soon as possible.</p> 107 108 <form class="contact-form p-4" action="/contact_form" accept-charset="UTF-8" method="post"><input type="hidden" name="authenticity_token" value="jQIb1bFNLMHSfF4dyaD_V2logHMZeW1UhlE-Pllh4MFaK6SXr9BAydhKEX3tdoj5Qlb6C59y39DmO44aCFMEkA" autocomplete="off" /> 109 <div class="form-group"> 110 <label for="name">Your Name:</label> 111 <input type="text" name="name" id="name" class="form-control" placeholder="Enter Name" required="required" /> 112 </div> 113 <div class="form-group"> 114 <label for="email">Your Email:</label> 115 <input type="text" name="email" id="email" class="form-control" placeholder="Enter Email" required="required" /> 116 <small id="emailHelp" class="form-text text-muted">*We'll never share your email with anyone else.</small> 117 </div> 118 <div class="form-group"> 119 <label for="phone">Your Phone Number</label> 120 <input type="text" name="phone" id="phone" class="form-control" placeholder="Enter Phone Number" required="required" /> 121 <small id="emailHelp" class="form-text text-muted">*We'll never share your phone number with anyone else.</small> 122 </div> 123 <div class="form-group"> 124 <label for="comments">Questions/Comments:</label> 125 <textarea name="comments" id="comments" class="form-control" rows="5" required="required"> 126</textarea> 127 </div> 128 <div class="form-group my-2">
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131<div data-sitekey="6LdE6qkUAAAAAHP728H5qLDzS_gCBeK0zhmwbCsj" class="g-recaptcha "></div> 132 <noscript> 133 <div> 134 <div style="width: 302px; height: 422px; position: relative;"> 135 <div style="width: 302px; height: 422px; position: absolute;"> 136 <iframe 137 src="https://www.recaptcha.net/recaptcha/api/fallback?k=6LdE6qkUAAAAAHP728H5qLDzS_gCBeK0zhmwbCsj" 138 name="ReCAPTCHA" 139 style="width: 302px; height: 422px; border-style: none; border: 0; overflow: hidden;"> 140 </iframe> 141 </div> 142 </div> 143 <div style="width: 300px; height: 60px; border-style: none; 144 bottom: 12px; left: 25px; margin: 0px; padding: 0px; right: 25px; 145 background: #f9f9f9; border: 1px solid #c1c1c1; border-radius: 3px;"> 146 <textarea id="g-recaptcha-response" name="g-recaptcha-response" 147 class="g-recaptcha-response" 148 style="width: 250px; height: 40px; border: 1px solid #c1c1c1; 149 margin: 10px 25px; padding: 0px; resize: none;"> 150 </textarea> 151 </div> 152 </div> 153 </noscript> 154 155 156 </div> 157 <input type="hidden" name="state" id="state" value="value New Mexico Drug Card" autocomplete="off" /> 158 <div id="general-ackbar"> 159 <input type="text" name="street_name" autocomplete="nope" tabindex="-1" style=display:none;> 160 <input readonly type="text" id="status" name="status" autocomplete="nope" tabindex="-1" class="" style=display:none; value="220906867117332"> 161 </div> 162 <input type="submit" name="commit" value="Submit" class="btn btn-primary" data-disable-with="Submit" /> 163</form> 164 </div><!-- main-content--> 165 </div> 166</div><!-- content wrapper --> 167 168<footer class="footer d-print-none"> 169 <div class="container"> 170 <div class="row"> 171 <div class="col-lg-12"> 172 <ul> 173 <li><a class="nav-link" href="/">Home</a></li> 174 <li><a href="/privacy-rights_and_practices">HIPAA Notice of Privacy Rights and Practices</a></li> 175 <li><a href="/usage-agreement">Usage Agreement</a></li> 176 <li><a href="/privacy">Website Privacy Policy</a></li> 177 </ul> 178 179 <p class="text-center disclaimer">This is not a medicare prescription drug plan. Program is privately supported.<br> 180 This is not a government run/affiliated/funded program.<br> 181 Discounts are only available at participating pharmacies.<br> 182 This program/card is a drug coupon. <strong>THIS IS NOT INSURANCE.</strong> <strong><a href="/disclosure">More Info</a></strong></p> 183 184 <p class="text-center"><a href="/kbcmn">Login</a> <strong>© 2005 - 2026 New Mexico Drug Card | All rights reserved.</strong></p> 185 </div> 186 </div> 187 188 </div> 189</footer> 190 191 192 193 </main> 194 </body> 195</html>
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