Renuology Order Form
Name
*
First Name
Last Name
MIVM Email
*
Phone Number
*
Please enter a valid phone number.
Order information
Billing address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please click here if your shipping address is the same as your billing address
Shipping address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please indicate your product order quantity (enter 0 if none)
*
Order Qty
Amino Blend 50mL Multi Dose Vial:
Concentration: (Proline 50mg, Arginine 100mg, Lysine 50mg, Citrulline 50mg)/mL:
Vial Price: $70($1.40/mL (OUT-OF-STOCK)
Ascorbic Acid (Preservative Free, Corn Free) 10mL Multi Dose Vial:
Concentration: 500mg/mL
Vial Price: $55 ($5.50/mL)
Ascorbic Acid (Preservative Free, Corn Free) 50mL Multi Dose Vial:
Concentration: 500mg/mL
Vial Price: $70 ($1.40/mL)
Vitamin B12 (methylcobalamin) 10mL Multi Dose Vial:
Concentration: 5mg/mL
Vial Price: $50 ($5.00/mL) (OUT-OF-STOCK)
Vitamin B-Complex (Thiamine, Riboflavin, Niacinamide, Panthenol, Pyridoxine) 10mL Multi Dose Vial:
Vial Price: $55 ($5.50/mL)
Vitamin B-Complex (Thiamine, Riboflavin, Niacinamide, Panthenol, Pyridoxine) 50mL Multi Dose Vial:
Vial Price: $85 ($1.70/mL)
Biotin 10mL Multi Dose Vial:
Concentration: 10mg/mL
Vial Price: $55 ($5.50/mL) (OUT OF STOCK)
Biotin 30mL Multi Dose Vial:
Concentration: 10mg/mL
Vial Price: $85 ($2.84/mL) (OUT OF STOCK)
Glutathione (Preservative Free, Corn Free) 10mL Multi Dose Vial:
Concentration: 200mg/mL
Vial Price: $55 ($5.50/mL)
Glutathione (Preservative Free, Corn Free) 50mL Multi Dose Vial:
Concentration: 200mg/mL
Vial Price: $85 ($1.70/mL)
L-Taurine 10mL Multi Dose Vial:
Concentration: 50mg/mL
Vial Price: $55 ($5.50/mL)(OUT OF STOCK)
L-Taurine 50mL Multi Dose Vial:
Concentration: 50mg/mL
Vial Price: $85 ($1.70/mL)(OUT OF STOCK)
Lipo-B (Methionine, Inositol, Choline and B12) 10mL Multi Dose Vial:
Vial Price: $60 ($6.00/mL)
Lipo-B (Methionine, Inositol, Choline and B12 )50mL Multi Dose Vial:
Vial Price: $90 ($1.80/mL)
Magnesium sulfate 2mL Single Dose Vial:
Concentration: 500mg/mL
Vial Price: $15 (OUT OF STOCK)
Magnesium sulfate 10mL Single Dose Vial:
Concentration: 500mg/mL
Vial Price: $20 (OUT OF STOCK)
NAD+ 1,000mg Lyophilized Multi Dose Vial with bacteriostatic water 10mL:
Concentration: 1,000mg/5mL
Vial Price: $110
Pyridoxine (vitamin B6) 10mL Multi Dose Vial:
Concentration: 100mg/mL
Vial Price: $55 ($5.50/mL)(OUT OF STOCK)
Pyridoxine (vitamin B6) 50mL Multi Dose Vial :
Concentration: 100mg/mL
Vial Price: $85 ($1.70/mL)(OUT OF STOCK)
Vitamin D3 10mL Multi Dose Vial:
Vial Price: $60 ($6.00/mL)
Vitamin D3 50mL Multi Dose Vial:
Vial Price: $125 ($2.50/mL)
Zinc sulfate 10mL Multi Dose Vial:
Concentration: 10mg/mL
Vial Price: $55 ($5.50/mL)
Acknowledgement:
*
By submitting this IV medication order, I confirm that I am a licensed prescribing practitioner, or that I am practicing under the supervision of a licensed Medical Director, and that I am acting within my authorized scope of practice. I attest that all information provided is complete and accurate, that I have personally evaluated the patient, and that I have determined this therapy to be clinically appropriate. I hereby authorize the dispensing pharmacy to compound and dispense the prescribed medication as ordered. I acknowledge that I am responsible for patient counseling, ongoing monitoring and follow-up, and compliance with all applicable state and federal prescribing regulations.
Submit
Should be Empty: