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!

To speak with a compounding pharmacist, please call us on 1-844-857-5588 between 9:30-6:30 EST Monday-Friday or email info@vlspharmacy.com.