Form No:

Date:

Billing Address

Name:

First Name

Last Name

Address:

City:

State/County:

Zip Code:

Country:

Contact No.:

Email ID:

Shipping Address (Same As Above)

Shipping Address 

(*If your Shipping Address is different from you billing Address please fill it in below)

Address:

City:

State/County:

Zip Code:

Country:

Contact No.:

Payment Details

(All credit card information is processed via Secure Servers and is protected with maximum security).

Credit Cards:

(Please Circle the Credit Card that you want to use)

MasterCard

Visa

American Express

Diners Club International

JCB Cards

Citibank eCards

Credit Card No:

Expiry Date:

Signature on Card:

Drug Name & Strength

Quantity Requested 

Example Drug 12mg

90 pills

1)

2)

3)

4)

5)

6)

Allegra 180mg (Fexofenadine)

2.00

Amlodipine 10mg (Amlodipine)

0.40

Amaryl  3mg (Glimepiride)

0.45

Paxil 20mg (Paroxetine)

0.80

Amoxil 250mg (Amoxicillin)

0.35

Pravachol 20mg (Pravastatin)

0.95

Antabuse 500mg (Disulfiram)

1.50

Prevacid 15mg (Lansoprazole)

0.45

Celecoxib 200 mg (Celecoxib)

0.85

Prilosec 20mg (Omeprazole)

0.45

Celexa 20mg (Citalopram)

0.49

Propecia 1mg (Finasteride)

0.70

Tadalafil 20mg (Tadalafil)

3.00

Prozac 20mg (Fluoxetine)

0.42

Cipro 500mg (Ciprofloxacin)

2.25

Remeron 30mg (Mirtazapine)

0.85

Clomid 50mg (Clomifene)

0.99

Singulair 10mg (Montelukast)

1.10

Fluconazole 150mg (Fluconazole)

4.00

Soma 350mg (Carisoprodol)

0.45

Doxycycline 100mg (Doxycycline)

0.43

Sporanox 100mg (Itraconazole)

1.70

Evista 60mg (Raloxifene)

0.85

Synthroid 100mcg (Levothyroxin)

0.18

Metronidazole 400mg (Metronidazole)

0.89

Tenormin 50mg (Atenolol)

0.33

Fosamax 70mg (Alendronate)

5.90

Topamax 100mg (Topiramate)

1.28

Glucatrol 5mg (Glipizide)

0.25

Toprol XL 50mg (Metoprolol)

0.50

Ultram 50mg (Tramadol)

0.75

Lamisil 250mg (Terbinafine)

4.00

Sildenafil Citrate 100mg (Sildenafil Citrate)

2.50

Lasix 40mg (Frusemide)

0.15

Hydrochlorothiazide 25mg (HCTZ)

0.15

Imitrex 100mg (Sumatriptan)

4.25

Lamisil 250mg (Terbinafine)

2.00

Lasix 40mg (Frusemide)

0.15

Sertraline 100mg (Sertraline)

0.95

Atorvastatin 20 (Atorvastatin)

0.90

Wellbutrin 150SR (Bupropion)

0.90

Azithromycin 250mg (Azithromycin)

1.50

Zocor 20mg (Simvastatin)

1.45

Zovirax 400 (Acyclovir)

1.45

Zovirax 400 (Acyclovir)

1.45

Nexium 40mg (Esomeprazole)

0.60

Zyprexa 10mg (Olanzapine)

0.99

Glucophage 500mg (Metformin)

0.30