This form is for existing customers only. New customers please use this form instead. All information obtained through this form is protected for your privacy and never shared or sold to outside associates or third parties. Customer ID number: Leave blank if you can't remember.  Contact Information First Name   Middle Initial Last Name   Telephone #  Area Code Number Fax #  Area Code Number *Email Address

Shipping Info: $9.99 Flat Rate Air Mail  Add $5.00 for Express Mail Service?  YesNo  Is your shipping information the same?  YesNo Leave blank if nothing has changed. Address   Address 2   City/Town   State/Prov   Zip Code Country

Medical Profile List any changes with any drug allergies.  Any additional medical history we need to be aware of? Please explain here.

Medication To Refill List the medications you would like to order.  Name of Medication  Strength eg. 30mg Quantity eg. 90tablets Generic or Brand Name*       GenericBrand       GenericBrand       GenericBrand       GenericBrand       GenericBrand       GenericBrand       GenericBrand       GenericBrand *Please note that if a generic is unavailable, brand name will be substituted at brand name price.

Billing Info  Is your billing information the same?  YesNo Leave blank if nothing has changed.  Card Type VisaMastercardAmexDiscover  Name as it appears on card  Card Number  Expire Date  Last three digits on back of card. Amex, last 4 digits on front of card.   Billing Address of Credit Card. This must match the mailing address of your monthly statements. If same as your shipping address, leave blank. Address   Address2   City/Town   State/Prov   Zip Code Country

Thank you for your order !