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 will return your text, please be patient with us. More important COVID-19 information HERE.
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