PEPTIDE REFILL REQUEST

FULL NAME *

First Name

Last Name

DOB *

MM

DD

YYYY

PHONE *

(###)

###

####

Address *

direct delivery from pharmacy

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

permission to charge card on file *

please call peptide line to provide new CC info if necessary

yes - charge card

no - update card

select peptides *

The Beauty Shot (GHK-Cu)

The Body Shot (CJC)

The Body Shot + (Tesamorelin/Ipramorelin)

The Clarity Shot (NAD+)

The Gut Pill (BPC-157)

The Healing Shot (BPC-157)

The Love Shot (Kisspeptin)

Youth Revival Cream