Prescription Request Form
The prescription that you requested should be available within 24 hours.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient Email: (If tracking is requested to be sent)
example@example.com
Refill Rx (If yes, no need complete Pt information)
Yes
Patient's Gender
*
Please Select
Male
Female
Patient's Phone Number
*
Please enter a valid phone number.
Patient/Practice Address (Not required if Refill)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Practitioner/Physician's Name
*
Practice Contact No. (Not required)
Please enter a valid phone number.
GLP's
Prescribed Medication:
Dose (mg)
mL
Qty
TA1
TA1 + Thymulin
Tesamorelin
Tesamorelin / Ipamorelin
Sermorelin
BPC-157
GLOW Blend
GHK-Cu
Epithalon
Selank
Semax
Testosterone Cypionate
CJC 1295
CJC 1295 / Ipamorelin
NAD+ 1000mg
Other Medication:
Dosing instructions:
*
Syringes Qty of 10 per bag (Can not exceed medication dosing volume)
Please Select
X1 Bags
X2 Bags
X3 Bags
X4 Bags
Special instructions for Pharmacy
Reconstitution Method
*
Pharmacy
Patient with Kit
Shipping Options:
*
Ship to Practice
Ship to Patient
Upload a photo of your prescription here instead of completing form above.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: