Patient Credit Card Form

VLS Pharmacy requires written permission to charge your credit card for all items (prescriptions, vitamins, medical supplies, and retail).

Please print this form, complete all areas and fax to: 855-491-0799 OR email to

Credit Card Form – Download PDF (click to download)

Thank you for your cooperation!

For compounded medications, please call: 1-844-857-5588. For all other matters, please call: 212-879-0910.