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Prescription No.,,,

Patient Name/LastFirst


Tel.No.--  Wanted Date/(MM/DD)

Medication Name if you are not sure the prescription number (Name & strength)

1. 2.

3. 4.

Payment method :Credit/card Other Method

Credit Card      Expired Date/ (MM/YYYY)

Credit Card Holder Last NameFirst Name

Special Direction

If you need more space for special order, please attach and fax to (323)277-8080


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For security reason
Print this out, fill the blanks and Fax to us.
Thank You!

Fax: 323-277-8089