Fax Order
Form : 1-800-420-8226 Customer Details Name .. ... Ph . Email . Fax Delivery Details Address . City State .. Zip Code Country .... Billing Address Details (if different from above) Address . City State .. Zip Code .. Country ... Order your Medications:
Credit Card Details: Type of Card Visa * Mastercard * American Express * Bankcard * Credit Card Number .. Expiry Date ... Card Holder Name . Security Code (Optional) .. Signature _____________________________________________________ MEDICAL INFORMATION
Doctors Name: .................................................................... City: ...................................................................................... State: ..................................................................................... Telephone Number: .............................................................. Do you have any known food or drug allergies? (Please tick one) Yes * No * If yes, please supply details: .................................................................................... .................................................................................................................................. .................................................................................................................................. Please list any medications being taken, including those not purchased from MedstoreInternational.com
Please fax the completed order form and your prescription to: 1-800-420-8226. When we receive your fax, your order will be processed. Thank you for ordering through MedstoreInternational | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||