Refills World Canadian Pharmacy .com Fax to 1-866-340-1838

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Customer ID number. (leave blank if you don't know it)

My shipping information has not changed. c My billing information has not changed. c Please refill what I ordered before and charge my credit card. c I would like to add new medications to my order. c (please remember to fax the new prescription to us)

Contact Information

First Name	Last Name	Address
			(   )	(   )
City	State	Zip	Phone	Fax

Medications to Order

Medication	Strength	Quantity

Shipping Information (Leave blank if no change)

Address
City	State	Zip

Payment Method (Leave blank if no change)

c Visa c MasterCard c Amex c Discover

Credit Card Information (Leave blank if no change)

Card Holder Name	Credit Card Number	Expiry Date
Address
City	State	Zip

Visa, Mastercard, Discovery, last 3 digits on back of card: Amex, last 4 digits on front of card:

I hereby waive my right to pharmacy counseling, as I have previously been counseled

c Yes c No

Signature _____________________________________

Date ______________

Remember $9.99 flat rate shipping will be added to every order. Document must be signed to be processed. One cent shipping with orders over $500.00.
Add $5.00 for express mail service. ___Yes ___No