Menu Close


The Card Pharm is Managed by W2.  First-Time Card Customers must chose “prepaid card visa” or “prepaid card mastercard”.

    Please chose Your Order

    Confirm your Order

    Personal Details

    Your First Name :

    Your Last Name :

    Your Email :

    Shipping and Billing Address (Must Be the Same)

    Street Address:



    Your Zip Code:


    Your Phone:


    Credit Card Type:

    Name on Credit Card:

    Credit Card Number:

    Card Holder Date of Birth: mm/dd/year

    Card Verification Number: The Three Digits in the back of your VISA, MasterCard Card.

    Expiration Date on Credit Card: mm/yyyy

    Health Questionnaires

    Date of Birth: mm/dd/year

    Your Height: ft-in

    Your Weight: Lbs


    1. I agree not to take any over-the-counter medicines without approval from my pharmacist.

    If you disagree, please explain why:

    2. I agree not to take medication if I am pregnant, breast-feeding, or trying to get pregnant.

    If you disagree, please explain why:

    3. Please list all current medical conditions including high blood pressure. Choose "None" if none.

    Specify all current medical conditions:

    4. Is there anything in your medical history that you consider to be relevant? If yes, please specify. Choose "None" if none.

    5. Please list all over-the-counter and prescription medications that you are currently taking and the length of time for each. Choose "None" if none.

    6. Please list all medications that you plan to take while on this program. Choose "None" if none.

    7. Please list all past or present allergies including allergies to any medications. Choose "None" if none.

    8. Please list all past surgeries and provide details including the condition that was treated with each surgery. Choose "None" if none.

    9. Please explain the specific medical reason for ordering this medication. The physician must know the exact nature of your medical problem in order to prescribe this medication. This cannot be left blank.

    I double checked the information and confirm all the information is correct , and I will contact you when my order has a problem. I will not ask charge back without contacting you. I also know the order cannot be cancelled and all the information can not be modified when I click "place order now" link

    (Visited 456 times, 4 visits today)