MyWeCareRX.com

Refills

	Name

Refill/Recon:

First Name:

Last Name:

Date of Birth:

	Contact

Street:

City:

State:

Zip Code:

E-mail:

Home Phone: eg: xxx-xxx-xxxx

Work Phone: eg: xxx-xxx-xxxx

	Comments Comments : ALL member information remains the same as the initial information. If you have any changes in Billing, Delivery, ETC please note them here in the comments section.

Payment Options - COD or CREDIT CARD

Shipping $30 plus $14 COD

Saturday Shipping Additional $14

COD (check here for COD):

Name as it appears on Card:

Credit Card Number:

Security Code: (usually 3 or 4 digits found on back of card)

Expiration Date (eg: xx-xxxx):

Billing Address:

Street:

City:

State:

ZipCode:

Shipping Address:

Street:

City:

State:

ZipCode:

When paying with check or money order a customer service representative will inform you as to whom to make payable to.