| www.valuepharmaceuticals.com
Thank you for downloading the Value Pharmaceuticals Fax order form. To place an order with us using this form, simply print a hard copy, fill in the required details, and fax it to us using the toll-free number: 1-800-234-9185. You can use the online Value Pharmaceuticals product catalogue (http://www.valuepharmaceuticals.com/public/home.ehtml) to locate the product you wish to order and copy the name, strength, quantity and price onto the order form. To clarify or gather any product information you cannot obtain through our site, you can leave a voice message on our toll-free phone: 1-800-234-9185 or email: enquiries@valuepharmaceuticals.com and we will respond to you. If you prefer, you can complete your order online by locating the product you require and following the online ordering instructions. We look forward to being of service to you Fax Order Form : 1-800-234-9185 Customer Details Name .. ... Ph . Email . Fax Purchase Code .. Delivery Details Address . City State .. Zip Code Country .. Billing Address Details (if different from above) Address . City State .. Zip Code .. Country ... Customer Information Drug Allergies
If Yes -- Please supply details .
Order your Medications:
Credit Card Details: Type of Card
Credit Card Number .. Expiry Date ... Card Holder Name . Security Code (Optional) .. Signature ------------------------------------------------------------------------------------ PERSONAL DECLARATION or PRESCRIPTION If you are ordering a product that requires a prescription in your country you need to either complete the Personal Declaration provided below or fax us your prescription. Whichever document we receive will be packed and shipped with your order. We treat all information supplied on this document as highly confidential. Neither Value Pharmaceuticals nor its suppliers will contact the doctor whose details are in the Personal Declaration or on the prescription. PERSONAL DECLARATION TO WHOM IT MAY CONCERN
health condition I suffer from only after consulting with a knowledgeable and competent medical practitioner (we recommend you include practitioners name, city, state and phone number here)
who has both a scientific and practical knowledge of their use. They are not new or investigational drugs and this delivery consists of less than a 90 day supply which complies with guidelines for the importation of medicines for personal use. As I need the enclosed products quickly for my personal health care, I request that you do nothing to delay its/their passage to me and in fact do all you can to ensure they reach me in a timely manner. Thank you and regards, (Name) . =============================================================== Please fax the completed form to 1-800-234-9185 We will process your order as soon as we receive your fax. If you are faxing your prescription, please ensure it is faxed with this form. NB if you would like us to mail this form to you please leave a voice message on 1-800-234-9185. We will contact you to receive your delivery address details. The fax order form will then be mailed to you for you to fax back to us. Please dont hesitate to pass a copy of this form to your family & friends | |||||||||||||||||||||||||||||||||||||||||||||||||||||