GlobalDrugsOnline.com

PO Box 35538, Bridgeport RPO
Richmond, BC, Canada V6X 4G6

Toll Free Phone: 1-877-221-3784 · Toll Free Fax: 1-866-725-1254 · www.GlobalDrugsOnline.com

 

Patient Information                                                                      WB-GDO

First Name:

Last Name:

Telephone Number:

(          )

Secondary Telephone:

(          )

Shipping Address: (Street & Apt. #) – if different from above

City:

State:

ZIP:

 

Have there been any changes to your health OR medications being taken (i.e. changes in strengths or quantities) since placing your last order?  _____ YES  _____ NO

 

If YES to the above, please describe in detail any changes below:

Medications Being Refilled

Drug Name

Strength

Quantity

Generics

(Y or N)

Price

(USD)

1.

 

 

 

 

2.

 

 

 

 

3.

 

 

 

 

4.

 

 

 

 

5.

 

 

 

 

6.

 

 

 

 

7.

 

 

 

 

8.

 

 

 

 

Shipping and handling fees are $10.00 per package, not per prescription.

Shipping

 

Total

 

 

Has your billing information changed since your last order?  ___ YES  ___ NO

 

If YES to the above, please complete the following:

 

*How would you like to pay for your medications? (Check one only)

 

___ Visa         ___ MasterCard

*Name on Credit Card:

 

*Credit Card Number:

 

*Credit Card Verification Number: (The verification number is a 3-digit number printed on the back of your card. It appears after and to the right of your card number on the signature field.)

 

 

*Card Expiry Date: ____ /____   (mm/yy)

Fax to 1-866-8725-1254 for Processing