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First and Last Name:*

Date of Birth:*

Phone number:*

Email:*

List prescriptions and/or supplements needed (please include dosage amount):

1. MEDICATION/ PRODUCT

DOSE / STRENGTH

QUANTITY or DAY SUPPLY

PHARMACY / OFFICE

2. MEDICATION/ PRODUCT

DOSE / STRENGTH

QUANTITY or DAY SUPPLY

PHARMACY / OFFICE

3. MEDICATION/ PRODUCT

DOSE / STRENGTH

QUANTITY or DAY SUPPLY

PHARMACY / OFFICE

4. MEDICATION/ PRODUCT

DOSE / STRENGTH

QUANTITY or DAY SUPPLY

PHARMACY / OFFICE

5. MEDICATION/ PRODUCT

DOSE / STRENGTH

QUANTITY or DAY SUPPLY

PHARMACY / OFFICE

ARE YOU AWARE OF ANY CHANGES TO YOUR MEDICATION FOR THIS REFILL?

Yes No

(***If Testosterone is included in your order, a signature will be required at time of delivery. You may have your order shipped to your place of business or a local Fed Ex location.)

Please list shipping address below: *

Please choose shipping delivery method below: (mark one of the options)

Ground shipping (3 to 5 business days) 2-day shipping Overnight shipping No Ship / Pick - up Only

If we already have your credit card information on file, please list the last 4 digits of the card:

Otherwise, please list your new credit card number and expiration date below:

Exp Date: (Month / Year)

THREE OR FOUR DIGIT SECURITY CODE:

Your financial information will be kept confidential!
Please allow 24 - 48 hrs for prescription refills to be processed and shipped.
Please allow 24 hours for your supplement orders to be processed and shipped from our office.

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