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 info@vlspharmacy.com.

Credit Card Form – Download PDF (click to download)

Thank you for your cooperation!

Due to high demand and call volume, please TEXT us with your refill requests: VLS Pharmacy: 844-857-5588 | New Drug Loft: 212-879-0910.
We are experiencing unprecedented delays in shipping. You are encouraged to order early, fill prescriptions in a timely manner, and when possible request 90-day supplies.
More important COVID-19 information HERE.
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