Special Value Services - Member ReConsults

Existing Members ReConsults

For Questions or Comments

	Name

First Name:

Last Name:

	Contact

E-mail:

Home Phone:

eg: xxx-xxx-xxxx

	Comments

ReConsult Payment and Delivery Options

	Payment Options

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

	Fedex Delivery Options	Please check one

	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

Expiration Date

Billing Address:

Street:

City:

State:

Zip:

Ship To Address:

Name:

Street:

City:

State:

Zip: