USCanadianPharmacy.com
EXISTING CUSTOMERS - Refills Only
Please fax this form to 1-866-266-9944

NOTES:
  1. THIS FORM IS FOR EXISTING CUSTOMERS ONLY. IF YOU ARE A NEW CUSTOMER PLEASE USE FORM A.
* Denotes a Required field. These fields are required to be filled in prior to us processing your order.
(Please print clearly)
*First Name:   *Last Name:  
*Phone:   Email:  
 

Please enter your prescriptions and Rx numbers that you wish to be refilled.

 

Have there been any changes in your billing information since your last order? If so please fill in below.
CREDIT CARD CHECKING ACCOUNT
* Name on Credit Card:   * Account Holder's Name:  
* Credit Card Type: Visa Mastercard * Account Number:  
* Credit Card Number:   * Bank Routing Number:  
* Expiration Date: Month_______ Year____________ * Drivers License Number OR Mother's maiden name:  
* Cardholder's Signature:  
 

Have there been any changes in your Health Profile since your last order? If so please fill in below.

 

Have there been any changes in your Delivery Address since your last order? If so please fill in below.


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