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1
Full Name
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First Name
Last Name
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2
Date of Birth
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3
Email
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example@example.com
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4
Phone Number
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Please enter a valid phone number.
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5
Type of Refill(s) needed
*
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Testosterone Cypionate
Semaglutide
CJC 1295/Ipamorelin
Sermorelin
Vitamin B12 Injections
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6
Delivery Method
*
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Ship to address on file (additional shipping fees apply)
Weekly in-office injection
EAST SIDE pick up: 6565 E Carondelet Dr Ste 301
NORTHWEST pick up: 2055 W Hospital Dr Ste 145
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7
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8
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