PEPTIDE REFILL REQUEST complete & submit the form below to request the refill process begin 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 Glow Show (BPC-157 + Thymosin B4 + GHK-Cu The Gut Pill (BPC-157) The Healing Shot (BPC-157) The Love Shot (Kisspeptin) - on backorder Youth Revival Cream select provider * Katie Scoggins - Dallas Lauren Walker - Austin NOTES please provide any information you'd like our providers to know with this refill request. Thank you for your order, we are so excited for you to continue your wellness journey with us.Your prescription is being processed. The pharmacy will provide tracking information upon fulfillment, and will deliver to the address provided. Please reach out to our VIP peptide line if you need anything; (737) 377-9960Please let us know if you have any questions. xx