Provigil Order Form - Better Life Pharmacy

  Affiliate ID: 2752    Fax Order and Prescription to: 

                              (316) 462-0701

 

  NAME: _______________________________________________________

  ADDRESS: ____________________________________________________

  CITY: ___________________________       STATE: __________________

  POST CODE: _____________________      COUNTRY: ________________

  PHONE NUMBER: __________________________________ 

  EMAIL: ___________________________________________

  PRODUCTS ORDERED

  Use our website http://www.betterlifepharmacy.com to search for products and latest prices. 

Drug

Strength

Quantity

Price

Provigil

200 mg

100

$ 82.32

 

 

 

 

Shipping

 

 

$ 12  or  $ 22    (standard or express)

 

 

Total

 

 

  Use prescription on file: (Circle option)               Yes      No  

   Are you a member of Betterlifepharmacy.com: (circle option)           Yes      No

 

    Note: By circling yes we will apply any rewards points due to you against

    this order unless otherwise directed not to this order will be credited directly to your account.

    If no, do you wish to become a member: (Circle option)            Yes         No

    Note: Becoming a member is free but you must have a valid email address. More

i    information can be found on our website:  http://www.betterlifepharmacy.com/Default.asp?ID=7.

  Affiliate ID: 2752        BILLING INFORMATION 

   NAME ON CARD: _______________________________________________

   CARD NUMBER: (Visa/Mastercard only) ___________________________________ 

   EXPIRY DATE: __________________          CCV: _________________________

   Note: All fields must be completed to bill the order. CCV is the three digit number on the

   back of the credit card.

 

  All billings appear as Better Life Pharm

 

   SIGNATURE OF CARD HOLDER: _________________________________

 

    DATE: ____________________________

   By signing the this form you agree to us billing your card using the prices as quoted with

   shipping cost being additional.

 

   Should have any concerns regarding your order you agree to contact us directly at

   service@betterlifepharmacy.com or our US Toll free number: 

   1-866-839-9581 or 1-888-523-9088.

 

   Please fax the completed form and any prescriptions to  (316) 462-0701.

 

   Orders are not approved or billed until we receive a copy of a valid prescription. Prescription must be less

   than one year from date of issue.

 

This site is for worldwide use. Consumers living in the United States who order prescription medications from pharmacies
outside the US do so at their own risk. Medfinder.com does not guarantee that the pharmacies listed on the site conform to
the importation requirements of the U.S. Federal Food, Drug and Cosmetic Act, the Controlled Substance Act or any other
laws. Consumers should make their own inquiries, consulting the laws of their country, before making any purchases, and
should be aware that importation of drugs into the United States in violation of these laws potentially could result in significant
civil and criminal penalties and fines.

 

 

 

 

 

 

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