Norphar.com Refill Form
All fields must be completed unless otherwise noted.
1. Enter your name:
First Name
Middle Name
Last Name
2. Enter your shipping and contact information:
Street
City/Town
State
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
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OH
OK
OR
PA
RI
SC
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TN
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UT
VA
VT
WA
WI
WV
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AM
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MH
MP
PW
PR
VI
Zip Code
Country
Phone (Home)
Phone (Work)
(optional)
Phone (Cell)
(optional)
Fax
(optional)
Email
(optional)
3. Enter additional shipping preferences:
Please provide any other shipping information. If you wish to have your order combined with a family member to save on shipping, please note here.
(optional)
4. Enter the medications you would like to order:
Please list
all medications you are currently taking
and the conditions for which they have been prescribed (if applicable). State a quantity for each drug you wish to order.
Drug Name
Strength
Directions for use
How long have you been taking this drug?
Quantity requested
Medical condition this drug is used to treat
Example Drug
12mg
1 tablet a day
8 months
90 pills
Thyroid
Note:
It is generally cheaper to get a 90-day supply. You will get 1 delivery charge instead of 3 and you will receive the benefit of volume discounts on most medications.
To minimize waiting time, please ask your physician to write the prescription for a 3-month supply plus 3 refills. Your initial order for each prescription will be delivered within 14 days in most cases. Refills should be delivered in approximately 10 days.
5. Read our return policy:
All sales are final. Be sure you order accurately to prevent problems. The law states:
"A pharmacist shall not accept for return to inventory any drug that has been previously dispensed"
Pharmaceutical Act Section 23(1) Return Medication (1)
I have read and understand the information above:
Yes
No
6. (If changed since your last order) Enter Credit Card Information:
Cardholder's Name
Credit Card Type
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Visa
MasterCard
Credit Card Number
For Mastercard only, please enter three-digit security code from back of card.
Example: xxxxxx
xxx
Expiration date:
Month
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01
02
03
04
05
06
07
08
09
10
11
12
Year
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2002
2003
2004
2005
2006
2007
2008
2009
2010
Billing Address:
If different than shipping address