REFILLS
Sermorelin 15mg /GHRP2/GHRP6
$199.00/MO
Ipamorelin 15mg / CJC 1295 6mg
$199.00/MO
Most Popular!
Sermorelin 15mg
$199.00/MO
Ipamorelin 15mg
$199.00/MO
Sermorelin 15mg /GHRP2/GHRP6
$249.00/MO
Ipamorelin 15MG / CJC 1295 6MG
$249.00/MO
Most Popular!
Sermorelin 15mg
$249.00/MO
Ipamorelin 15MG
$249.00/MO
IGF-1 BLOOD TEST
$99.00
  • IGF-1
  • Cbc
  • Cmp
  • Cardio iq lipid panel
  • Testosterone free and total
  • Free T-3
  • Free T-4 TSH
  • Estradiol
  • FSH & LH
  • PSA (males) / Progesterone (females)
Complete Hormone Evaluation
$199.00
  • Cbc
  • Cmp
  • Cardio iq lipid panel
  • Testosterone free and total
  • IGF-1
  • Free T-3
  • Free T-4 TSH
  • Estradiol
  • FSH & LH
  • PSA (males) / Progesterone (females)
Most Popular!
No Blood Test
$0.00

I do not request current hormone level testing at this time.

HAVE A COUPON CODE?

HORMONE THERAPY ENROLLMENT FORM

PATIENT INFORMATION

= required

FIRST NAME First name is required.

LAST NAME Last name is required.

STREET ADDRESS (Shipping Address | No PO Boxes) Address is required.

ADDRESS LINE 2

COUNTRY Country is required.

STATE State is required.

STATE State is required.

CITY City is required.

ZIP CODE Zip code is required.

EMAIL ADDRESS Email is required.

CELL PHONE NUMBER Cell phone is required.

MEDICAL INFORMATION

= required

GENDER Gender is required.

DOB (MM/DD/YYYY) Date of birth is required. Date of birth is invalid.

HEIGHT (FEET / INCHES) Height in feet is required. Height in inches is required.

WEIGHT (LBS) Weight is required.

BLOOD PRESSURE Blood pressure is required.

PULSE Pulse is required.

REASON FOR TREATMENT Reason for treatment is required.

PRODUCT USAGE

TOBACCO HOW OFTEN An answer is required.

ALCOHOL HOW OFTEN An answer is required.

CAFFEINE HOW OFTEN An answer is required.

OTHER PRODUCT USAGE

ALLERGIES (SELECT ALL THAT APPLY).

A selection is required.

Other allergy is required.

MEDICAL CONDITIONS (SELECT ALL THAT APPLY).

A selection is required.

Other condition is required.

OVER THE COUNTER MEDICATIONS (SELECT ALL THAT APPLY).

A selection is required.

Other medication is required.

MEDICAL CONDITIONS/DIAGNOSIS?
FAMILY HISTORY (FATHER, MOTHER, SIBILINGS ONLY)
A selection is required for each condition.

Heart Disease

Relationship is required.


High Blood Pressure

Relationship is required.


Diabetes

Relationship is required.


Arthritis

Relationship is required.


Skin Disorders

Relationship is required.


Cancer

Relationship is required.

WOMEN ONLY
= required

ANY BREAST/FEMALE ORGAN CANCER? An answer is required.

ARE YOU CURRENTLY PREGNANT? An answer is required.

ARE YOU CURRENTLY BREAST FEEDING? An answer is required.

HAVE YOU EVER HAD AN ABNORMAL PERIOD CYCLE? An answer is required.

LAST MENSTRUAL CYCLE? (MM/DD/YYYY) An answer is required. Last menstrual cycle date is invalid.

CURRENT FORM OF BIRTH CONTROL? (TYPE N/A IF NOT APPLICABLE) An answer is required.

HEAVY MENSES? An answer is required.

HOT FLASHES OR NIGHT SWEATS? An answer is required.

DECREASED LIBIDO? An answer is required.

DEPRESSIVE EPISODES? An answer is required.

PAST OR PRESENT HORMONE THERAPY? An answer is required.

TROUBLE SLEEPING? An answer is required.

MOOD SWINGS? An answer is required.

HEADACHES? An answer is required.

INABILITY TO CONCENTRATE? An answer is required.

WEIGHT GAIN? An answer is required.

HORMONE REPLACEMENT THERAPY QUESTIONS
= required

PAST OR PRESENT HORMONE THERAPY? An answer is required.

PROSTATE CANCER? An answer is required.

PROSTATE ENLARGEMENT? An answer is required.

TESTICULAR CANCER? An answer is required.

TESTICULAR PAIN/SWELLING? An answer is required.

ERECTILE DYSFUNCTION? An answer is required.

DECREASED LIBIDO? An answer is required.

DECREASED ENERGY? An answer is required.

BREAST ENLARGEMENT? An answer is required.

DECREASED MUSCLE MASS? An answer is required.

WEIGHT GAIN/INCREASED ABDOMINAL FAT? An answer is required.

DECREASED MOTIVATION? An answer is required.

INABILITY TO CONCENTRATE? An answer is required.

DEPRESSIVE EPISODES? An answer is required.

PATIENT AUTHORIZATION AGREEMENT AND CONSENT
TERMS & CONDITIONS

You must agree to the Terms & Conditions.

CONSENT TO TELEHEALTH

You must agree to the Telemedicine Policy.

PLEASE SIGN ABOVE USING YOUR CURSOR TO ACKNOWLEDGE YOU'VE READ AND UNDERSTOOD ALL TERMS & CONDITIONS

Weight-Loss Consumer Bill of Rights 501.0575

“Off Label” Use of HCG
Statement from the FDA

IMPORTANT INFORMATION

PAYMENT & SHIPPING

= required

SHIPPING METHOD Shipping method is required.

PAYMENT METHOD Payment method is required.

COUPON CODE

Please mail your check to:

Enrollment Summary

PROGRAM DETAILS

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PROGRAM ADD-ONS

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BLOOD WORK

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OTHER ITEMS

DOCTOR CONSULTATION (FREE FOR THE MONTH OF October)

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FREE


Sub-Total:
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Total:

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