Prescription Request Form

The prescription that you requested should be available within 24 hours.

Practice Supply (Is this for Office Use)

Patient's Name

First NameLast Name

Patient's Date of Birth

Date

Patient Email: (If tracking is requested to be sent)

example@example.com

Refill Rx (If yes, no need complete Pt information)

Patient's Gender

Patient's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Shipping Address (Not required if Refill)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Bill to address: (If multiple locations)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Practitioner/Physician's Name

Practice Contact No. (Not required)

Please enter a valid phone number.Format: (000) 000-0000.

Prescribed Medication:

Medications:

Rows	Dosage (mg's)	Quantity
GLP-1 S (5,10,20, 50mg)
GLP-2 T (5,10,30,40,50,60,100,120mg)
GLP-3 R (12, 24, 60mg)
AOD 9604 5mg
TA1 10mg
BPC-157 (10,20mg)
CJC 1295 (with Dac) (5,10mg)
CJC-1295 no DAC (5,10mg)
CJC 1295 / Ipamorelin (5/5mg)
DSIP (5,10mg)
Epithalon (10/50mg)
GLOW Blend (50,70mg)
GHK-Cu (50,75mg)
GHRP-2 5mg
GHRP-6 5mg
Ipamorellin 10mg
KPV 5mg
MOTS-C (5,10,20mg)
MT II (Melanotan II 10mg)
MT I (Melanotan I 5mg)
NAD+ 1000mg
PT-141
Selank (5,10mg)
Semax (10/30mg)
Sermorelin (5,10mg)
Wolverine Blend (BPC-157 10mg / TB500 10mg)
4X Blend (GHRP-2 5mg, Tesamorelin 5mg, MGF 500mcg, Ipamorelin 2.5mg)
TA1 + Thymulin 10mg/6.4mg
Tesamorelin 10mg
Tesamorelin / Ipamorelin (5/5mg) (10/5mg)
Testosterone Cypionate
Peptide DNA Test
Wellness DNA Test (Mini)
Wellness DNA Test (Supreme)
Wellness DNA Performance

Other Medication:

Dosing instructions:

Syringes Qty of 10 per bag (Can not exceed medication dosing volume)

Special instructions for Pharmacy

Reconstitution Method

Shipping Options:

Rx Image

Signature

Date Signed

Date

GLP's