Reorder Form
Name_______________________________ Address_________________________
City_________________________________ State___________________________
Phone (____) ________________________ Zip Code________________________
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Medication Being Ordered |
Dosage or Strength |
Quantity |
Generic Substitution Yes or No? |
Price in US dollars |
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Easy off caps Child resistant caps |
Sub total
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$ US |
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Shipping
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$ 10.00 US |
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Total
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$ US |
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Thank you for ordering from Glenway
Pharmacy.
To reorder please mail this form,
or for faster service fax or phone in your order.
Please allow for 7-14 days for
shipping time.
**Now visit us on line at www.glenwaypharmacy.com