Refill Order Details Complete form and fax to: 1-866-91-DRUGS
Contact Information       First Name Init Last Name   Address         City State Zip Country (   ) (   ) Phone Fax Refill Order Details Medication Strength Quantity RX Price       Yes No         Yes No         Yes No         Yes No         Yes No         Yes No     Shipping 15.00 USD   Total   Shipping Information   Address       City State Zip Payment Method  Visa  MasterCard Credit Card Information       Card Holder Name Credit Card Number Expiry Date Do you want us to use generic drugs to fill your order and save you even more money? Yes No I hereby waive my right to pharmacy counseling, as I have previously been counseled Yes No Please do not contact me regarding this order, rather ship medication described above Yes No I understand that all prices quoted and charges to my credit card will be in U.S. Dollars Yes No
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