Prescription Request Form
The prescription that you requested should be available within 24 hours.
Requested Date
-
Month
-
Day
Year
Date
Patient's Name
First Name
Last Name
Patient's Date of Birth
-
Month
-
Day
Year
Date
Patient's Gender
Please Select
Male
Female
Patient's Phone Number
Please enter a valid phone number.
Patient's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Practitioner/Physician's Name
First Name
Last Name
Practice Contact No.
Please enter a valid phone number.
Prescribed Medication:
Dose (mg)
mL
Qty
GLP-1 S
GLP-2 T
TA1
TA1 + Thymulin
Tesamorelin
Tesamorelin / Ipamorelin
Sermorelin
BPC-157
GLOW Blend
GHK-Cu
Epithalon
Selank
Semax
Testosterone Cypionate
CJC 1295
CJC 1295 / Ipamorelin
Other Medication:
Reconstitution Method
Pharmacy
Patient without Kit
Patient with Kit
None
Shipping Options:
Ship to Practice
Ship to Patient
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Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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