EXISTING CUSTOMER REFILL
FORM
INSTRUCTIONS:
This form is
for existing customers only. Please print
clearly and complete both pages. All fields with * must be filled to be
valid.
Fill
out your personal information and mark which
option
applies to you in the refill order request
portion.
Once you have completed the form fax this form along
with your new prescriptions to us
at
1-866-879-2441.
All
refill requests will be processed within 24 hours
of receiving all required information.
*PERSONAL INFORMATION:
*First Name:
_____________________ *Last
Name: ________________________
*Telephone #:
____________________ Email:
___________________________
*REFILL ORDER REQUEST:
** REMEMBER TO FAX YOUR
PRESCRIPTION(S) FOR ANY NEW MEDICATION(S) THAT YOU HAVE
ORDERED!
*WHICH
MEDICATIONS (name,
dosage, & quantity)
WOULD YOU LIKE TO ORDER?
Just a reminder: all new
medications ordered will require a prescription to be either mailed or
faxed to us.
Current New
Medication Name
Dosage Quantity
___________________
_______
_________
___________________
_______
_________
___________________
_______
_________
___________________
_______
_________
*PAYMENT
METHOD:
Credit card type:
New credit card #
______________________
Expiry_________
CVN#_______
*SHIPPING/MAILING ADDRESS AND MEDICAL HISTORY:
Please indicate any changes
to your mailing/shipping address since your last order:
Please let us know of any
changes in your health since the last order:
PLEASE
PRINT THIS FORM AND FAX TO
1-866-879-2441