www.verybestmeds.com - Consultation Request Form
  Section 1: Customer Account Information
First Name:  (Complete First Name - No Initials)
Last Name:
Email Address: (Example: yourname@aol.com)
 
NOTE: Notifications of your order status will be sent via email.
Best telephone number
to contact you:


  Section 2: Shipping/Contact Information
Shipping Method:
 
NOTE: When the package is delivered, an adult
must be present to receive the shipment.
Shipping Address:  
Address Line 1:
Street address, company name, c/o (No P.O. Boxes)
Address Line 2:
Apartment, suite, unit, building, floor, etc.
City:
State:
NOTE: If you CANT find your state in the drop down menu above, we are not able to provide services to the residents of your state at the time. We appologize for the inconvenience.
ZIP/Postal Code:
Country:


  Section 3: Payment Method
Credit Card
 
Card Type:
Card Holder: (Exact Name on Credit Card Bill)
Card Number:
CVV2: (The 3 or 4 digit number on the back of your card) More Info
Expiration Date:
C.O.D. (Payment on Delivery)
  Money Order/Bank Certified Check
This delivery method is ideal for persons who feel uncomfortable entering payment information over the Internet. The additional fee of $8.95 covers the return and handling of your payment.

No Personal Checks. Money Order/Bank Certified Check payable to A.H.A. LLC

Billing Address:  
  Same as Shipping Address
Address Line 1:
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
City:
State:
ZIP/Postal Code:
Country:
Alternative / Billing Phone Number:


  Section 4: Your Request and Your Current Medication Selection
Doctor Consultation -
Note: consultation fee varies ($173-$193) depending on the state where you live, higher consulation fee for some states covers addtional doctor requirements and logistics for those states ($193 - AZ, FL, CA, CO, MT, NM, NY, OR, TX, WY)

Select a medication that you are currently taking and that is referenced in your medical records.
NOTE: After you will select a medication this form will refresh with a questionaire. Please scroll down the page and fill it out to complete your request


Medication: