Andre Tarin - Patient Refill Request

Patient Refill Request

Scottsdale, AZ
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Email*
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Phone Number*
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Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Refill(s) Needed:*

Testosterone CypionateEstradiol CypionateVitamin B12 InjectionsSemaglutide/PyridoxineSermorelinTirzepatide/PyridoxineHexarelinNAD+ Injection/Infusion (Please specify in box below)Hairloss/Skincare (Please specify in box below)Nandrolone DecanoateProgesterone
Delivery Location*
Delivery Method*
Additional Comments
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