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Medication Refill Request

Any and all orders placed after Thursday at 12pm will not be processed until the following Monday. The office is CLOSED Friday-Sunday weekly.
For questions/concerns please text: (207) 400-5826 or call (207) 893-8918
NOTE: This order form is ONLY for patients who have had a consult with one of our Medical Providers

Your responses will be reviewed by the clinic to ensure you are a current patient before the order is submitted to the pharmacy.

Please click HERE to book a follow-up appointment.

PLEASE schedule an appointment if you have not been seen in the last 2 months
Please Answer this question if you have not done so before: What other concerns do you have?*

Anti-Aging: fine lines, wrinkles, texture, etc.Hair removalHormone Health/OptimizationFacial Care: Chemical peels, facials, etc.Body SculptingOther
Your Name (First & Last Name)*
Date of Birth*
Your E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
# of units on syringe you are taking or planning on taking*
If just starting, unsure, or are a HRT patient, put 0 or 4
Total pounds lost*
Current Weight*
Pick up or Ship*
Please choose SHIPPING in the MY PRODUCTS section and add to cart ONLY if you are shipping to your home.
Do you need more syringes?*
Additional Info that we should know, or updates to share.
HORMONE THERAPY PATIENTS: Please write what you are ordering in this box if you know

PLEASE READ BEFORE CONTINUING:

THIS IS ONLY FOR EXISTING SEMI WEIGHT LOSS PATIENTS. TIRZ, HRT, AND NEW PATIENTS CAN DISREGARD.

We are now using STRIVE PHARMACY and the concentration of your medication is higher. Please follow the instructions on your package.

YOUR DOSE WILL BE HALF (1/2) OF WHAT YOU WERE TAKING FROM HALLANDALE

If you did NOT half your dose (from Hallandale formula) on the order form, PLEASE return to the previous page by clicking the "BACK" button below.

**Also, please note that shipping times may be longer than normal due to all the other compounding pharmacies ceasing production. Plan for 7-10 business days to be safe**

Also NOTE- the medication will now be pink due to the addition of the B12 and Glycine

Please double check that the amount of units corresponds with what you are placing for an order. If not-it will delay processing.
CHECK THIS BOX TO CONTINUE:*

I have read and understood that my medication may be a different dose and formulation than my previous order and I have ensured that my order form is correct. I understand that any errors may result in delayed processing.

My Products*

SHIPPING(If shipping to YOUR HOUSE) *hormone patients can disregard*

$32.00 Quantity

NEW Start Weight Loss Program (S)For your very first vial after your consult- S

$425.00 Quantity

Weight Loss Program (8-29)Choose this package if taking 8-29 units per week.

$350.00 Quantity

Weight Loss Program (30-50)Choose this package if taking 30-50 units per week.

$400.00 Quantity

Weight Loss Program- TIRZ (25-99)Select this package if you are taking 25-99 units per week.

$525.00 Quantity

Weight Loss Program- TIRZ (100-150)Select this package if you are taking 100 units or more per week.

$650.00 Quantity

NAD (5-10 weeks depending on dose)By replenishing your body’s levels of NAD+, you can fight the signs of aging, including: Increased energy Decreased inflammation Improved endurance Pain relief Improved memory and concentration Better sleep Improved mood

$250.00 Quantity

Biotin 10ml (10 weeks)

$150.00 Quantity

B12 (10 Weeks) (Methylcobolamin)

$150.00 Quantity

Lipo-Mino (10 Weeks)Blend of: B1, B2, B6, B12, Inositol, Choline & Methionine This blend helps with fat burning, energy and supports a healthy immune system.

$200.00 Quantity

Men's Hormone Replacement ProgramFor patients that are currently enrolled in one of our Hormone Replacement Therapy Programs. Please disregard the shipping charge

$ Free Quantity

Women's Hormone Replacement ProgramFor patients that are currently enrolled in one of our Hormone Replacement Therapy Programs, please disregard the shipping charge. Add what hormones you are currently taking in the NOTES section.

$ Free Quantity

Pentadeca Arginate (BPC 157)Pentadeca arginate supports tissue repair, reduces inflammation, and enhances cellular healing by activating the body's natural regenerative pathways.

$300.00 Quantity

Methylene BlueMethylene blue boosts cellular energy, enhances brain function, and supports detoxification with antioxidant and neuroprotective benefits.

$100.00 Quantity

15mg SermorelinSermorelin stimulates natural growth hormone production, supporting improved sleep, fat metabolism, muscle tone, and overall vitality.

$200.00 Quantity

30mg Sermorelin

$375.00 Quantity

TB500TB500 promotes tissue repair, reduces inflammation, and accelerates healing by enhancing cell migration and regeneration.

$300.00 Quantity

Enter coupon

Total

$0.00

You can still use your HSA, FSA or HRA card

There is also the PayPal pay in 4 option that is similar to Afterpay

You can use your regular Debit/Credit Card even if you do not have a PayPal Account. Once you click "PayPal" you will see the button on the right that says "use debit/credit card"

PLEASE DOUBLE CHECK SHIPPING HAS BEEN ADDED TO CART (IF SHIPPING TO YOUR HOME) BEFORE CHECKING OUT.
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
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Medication Refill Request

For questions/concerns please text: (207) 400-5826 or call (207) 893-8918