REORDER FORM

Your Full Name .................................................. Address .................................................. City .................................................. State .................................................. Zip/Postal Code .................................................. Country .................................................. Phone Number (........)........................................ Email .................................................. Medication Being Ordered Strength/Dose Quantity Generic (Yes/No) Price(US$)

*We are required to dispense pills in child resistant containers unless indicated* Easy off caps Shipping Charge: $10.00 US Total: $___________US

Credit card information

Cardholder(name on card) _________________________________________________   Cardholder address _______________________________________________________   Credit card city _______________________________________________________   Cardholder state _________________________________________________________   Cardholder zip code ______________________________________________________   Credit card number _______________________________________________________                                     Visa       MasterCard   Credit card Security Code (3 digits) _________________________________________   Cardholder expiry ______________________________________________________     Signature: ____________________________ Date: _________________________