MEDICATION ORDER FORM

MEDICATION ORDER FORM

All orders will be ready within 5-10 days after submission. You will be texted when your order is ready.
Order Date*

MonthDayYear
Date
Customer Name*

First NameLast Name
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
WEIGHTLOSS MEDICATION MENU*
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Semaglutide & L-Cartinine 0.25 mgSemaglutide compounded with L-cartinine for weightloss 0.25 mg
$450.00 Quantity
Item subtotal:$0.00



Semaglutide & L-Cartinine 0.50 mgSemaglutide compounded with L-cartinine for weightloss 0.50 mg
$550.00 Quantity



Semaglutide & L-Cartinine 1 mgSemaglutide compounded with L-cartinine for weightloss 1mg
$625.00 Quantity



Semaglutide & L-Cartinine 1.5 mgSemaglutide compounded with L-cartinine for weightloss 1.5mg
$650.00 Quantity



Semaglutide & L-Cartinine 2 mgSemaglutide compounded with L-cartinine for weightloss 2mg
$699.00 Quantity



Semaglutide & L-Cartinine 2.5 mgSemaglutide & L-cartinine for weightloss 2.4mg
$750.00 Quantity



Tirzepatide 5mgTirzepatide compounded with L-cartinine for weightloss 5mg
$950.00 Quantity



Tirzepatide 10mgTirzepatide compounded with L-cartinine for weightloss 10mg
$1,800.00 Quantity



PhenterminePhentermine for weightloss. 30 day supply.
$150.00 Quantity



Total

$0.00
Payment Method*
Select your payment method. If you have a prepaid membership, you will not be charged. If your membership has run out, you will automatically be charged to your credit card on file. Any questions regarding payment forms call the office at 310.670.1920.
Credit Card Number (If no number supplied, card on file may be charged or no order will be filled)
Please enter your credit card number, expiration date and CID for all charges. If payment not provided order may not be fulfilled.
Reminders
ORDER SUBMISSION: Please allow 5-10 business days to fulfill your order. You will be notifed when your order is ready for pick up.

RETURNS: All sales are final.
By signing below I understand all sales are final and my card on file will be charged for the order if it has not yet been paid. Signature*

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MEDICATION ORDER FORM

Reminders