TIMELESS RX

Name

First NameLast Name

Email

example@example.com

Date of Birth

Date

How would you like to receive your order? **NO MEDICATION CAN BE SHIPPED OUTSIDE OF LOUISIANA**

Pick up in Covington or Metairie

Confirm Your Shipping Address **NO MEDICATION CAN BE SHIPPED OUTSIDE OF LOUISIANA

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

LAST 4 DIGITS OF PAYMENT METHOD

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.

PLEASE KEEP IN MIND THAT WE WILL CHARGE YOUR CARD ON FILE FOR ALL PURCHASES UNLESS TOLD OTHERWISE.

Hormone Replacement

Supplements

Weight Loss **PLEASE BE AWARE, OUR BELLA WILL NO LONGER CONTAIN PHENTERMINE**

How many vials would you like?

Do you need syringes?

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

Refill Request