Special Value Services - Existing Members

Existing Members

For Questions, Comments or Refills

	Name

First Name:

Last Name:

	Contact

E-mail:

Home Phone:

eg: xxx-xxx-xxxx

	Comments

For Refills on previous prescriptions

	Payment Options

	Standard Payment - Credit Card:
	Payment upon receiving your RX-COD:

	Fedex Delivery Options	Please check one

	Fedex Priority Overnight - $30.00
	Fedex Standard Overnight - $26
	Fedex 2 Day Delivery - $22
	Fedex Saturday - $44

	COD Delivery Options

COD, add additional $14.00

No
Yes

	CREDIT CARD INFORMATION

Type of Card:

Visa
Mastercard

Name as shown on card:

Card Number

Card Security Code

Expiration Date :

Billing Address:

Street:

City:

State:

Zip:

Ship To Address:

Name:

Street:

City:

State:

Zip:

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