Refill Request

Refill Request

Billing/Order Form
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
DL or SS Number*
How would you like to receive your order? If ordering Testosterone please select ship*

Pick UpShip
Pick up in Covington or Metairie*

CovingtonMetairieShip
Payment Information*

Credit Card Number

Expiration Date

CCV State / Province

Postal / Zip Code
Confirm Your Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please be aware all prescriptions for Testosterone will now be shipped directly to the address provided above from the pharmacy. Please be aware all shipments have a turnaround time of 5-7 business days. Prescriptions for Testosterone are no longer available for pick up in clinic.
Hormone Replacement

Anastrazole x10 $45Anastrazole x20 $90SERMORELIN $240SERMORELIN x3 $650CJC $230 each3 CJC $600Clomid $4.00 eachFemale Test VIal $135GONDALOREN HCL $110BPC-157 $225NAD Bottle $230NAD Injection $50Oxytocin Nasal Spray $120PT 141 $200Sarcrotropin $225Sildenafil Sublingual $15/eachSildenafil Capsules $15/eachTestosterone $180Timeless Advanced Hair Formula $110 buy 3 for $300
Supplements

Adrenotone $30Annatto-E 300 $41Annatto-GG $71Berberine Synergy $46Brain Vitality x60 $74.50CatecholaCalm $52.50CLA $40ColonMax $31CO-Q 10 $50Crave Arrest $ 63DHEA $30Dim Evail $36DimPro $46.50Endo Trim $62K2-Vit D $37L-5-MTHF (Folic Acid) $74Liposomal Gluthiathione $50Liposomal Vit C $40Magnesium Citrate $37Metabolic Synergy $87Melatonin Liquid $37Nutrafol Women $80Nutrafol Postpatrum $80OmegAvail Fish Oil $35Osteo Foce $38Pregnenolone CRT $28Progest-Avail $41.50R-Alpha Lipoic Acid $35Vitamin B-6 Liquid $26Zinc Glycinate $37Brain Vitality $74.40
Weight Loss

Bella $130 *Please know Bella is on back order, orders will be fulfilled accordingly.*Lipolean Bottle $175Tirzepatide $200Tirzepatide 3ML $500Tirzepatide 5ML $750Semaglutide 1ml $135Semaglutide 3ml $325Semaglutide 5ml $515
How many vials would you like?
Do you need syringes?*

NoIMSubQ
Only submit this form once. Once this form is submitted, please do not try to request the order by phone or through the office or you risk double processing. Shipping and tax will be added to all orders. Add any additional information below. All Sales final

How many Sildenafil would you like to order today?*
Please be aware all prescriptions for Testosterone will now be shipped directly to the address provided above from the pharmacy. Please be aware all shipments have a turnaround time of 5-7 business days. Prescriptions for Testosterone are no longer available for pick up in clinic.

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