Fax your completed forms to: 1-866-982-9542

Order Form

Medication Order Form

Please use the following form to indicate the type and quantity of each prescription you would like BEST-MEDS to fill for you. You can obtain the medication name, dosage, quantity and price either from our website at www.BEST-MEDS.com, our printed price sheet, or by contacting one of our customer service representatives at 1-888-510-5105. Please make certain that the drug type, dosage and quantity matches the prescription that you will be submitting with your order.

Medication Dosage Qty Price SKU                                                                       Add shipping $14.95   Total billed to card

Billing Information

Date:   VISA MasterCard AMEX Discover

Cardholder's Name:						Card Number:
Address:						Expiration Date:
City State ZIP

Cardholder's Signature: Best-Meds.com 7 - 1391 St. James St. Winnipeg, Manitoba R3H 0Z1 Tel: 1-888-510-5105 Fax: 1-866-982-9542 www.BEST-MEDS.com

CVV2 Number (as described below)   5521 2365 1226 2348 321   The VISA/MC CVV2 # is the last 3 digits in the signature panel of the back of your credit card.   3713 1234 5678 9011   On the AMEX card, it is the four digits above and to the right of your account number on the front of your card.

For Office Use Only
Referral Code:	Customer No:                                   Order No:
Date Entered:	Entered into system: Yes

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