Want to get started, or request a refill? To Expedite your order please fill out the form and we will contact you within the next Business Day! Medication Refill Form HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.How did you hear about our website? About YouFirst Name(Required) First Last Name(Required) Last Date of Birth(Required) MM slash DD slash YYYY Email(Required) Preferred Phone Number(Required)Preferred Contact Method(Required) Email Phone Call Other Have you had a change of address?(Required) Yes No Not Sure Other If you have a change of address or you are not sure, please list the address you want your order sent to: Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Is this address Temporary or Permanent Permanent Address Other If Temporary, select other and provide how long you will be at this temporary address.Move Has your preferred payment method changed?(Required) Yes No, Please charge the existing card on file Other Credit Card Number Expiration Date (mm/yy) Name On Card: Is this Card New Permanent Payment Method Use for this purchase only Other Please select medications you would like to reorder or medications that you are interested in* Testosterone Cypionate 200mg 10ml Omnitrope 5.8mg Semaglutide 2.5mg/ml 2mL Vial Human Chorinonic Gonadotropin 10,000 Units (Pregnyl) Testosterone Sublingual Troches Sildenafil 100mg Tablets Tadalafil 10mg Tablet Tadalafil 20mg Tablet Dutasteride .5mg #90 Testosterone Cream *If you do not see the medication or quantity you would like, please call the office at (888) 333-8629 for further assistance.If you have any questions for our clinic, please ask away in the box below and we will reach out as soon as possible! Or you can give us a call at our toll free number (888) 333-8629!Didn't See What You Were Looking For? Please provide any questions or comments below:
