Refills This form is for EXISTING patients only. NOTE: All Refills will be reviewed by Physicians first. If you are not approved, your request will be cancelled and you will be notified. Please select your refill request items below: HCG Diet Program - 26 Days - $297Injections - 5,000 IU HCGOral Pellets / Troche - 10,000 IU HCGOral Drops - 8,000 IU HCGHCG Diet Program - 46 Day - $397Injections - 10,000 IU HCGOral Pellets / Troche - 20,000 IU HCGOral Drops - 16,000 IU HCGMixing Solution UPGRADELipotropic MIC + B12 - $97ULTRA BURN - Weight LossUltra Burn Injections - 10ml - 40 Days - $147SupplementsTotal Body Colon Cleanse – 2 Week Super Cleanse #128 - $49Price: $49.00 Quantity: Adrenal Tea Complex Formula #30 - 49Price: $49.00 Quantity: Calcium Pyruvate 750 mg (Fat Burner) #30 - $49Price: $49.00 Quantity: Multi-Vitamin/Mineral Supplement #120 - $49Price: $49.00 Quantity: Meal Replacement PacksVanilla - HCG Diet Meal Replacement Pack - $4.97Price: $4.97 Quantity: Chocolate - HCG Diet Meal Replacement Pack - $4.97Price: $4.97 Quantity: Strawberry - HCG Diet Meal Replacement Pack - $4.97Price: $4.97 Quantity: HGH PatientsNorditropin 5mg HGH PenPrice: $505.00 Quantity: NorfiFlex Pen Neeedle Tips (Pack of 100)Price: $30.00 Quantity: Omnitrope HGH - 5.8mg - Human Growth HormonePrice: $455.00 Quantity: Sermorelin - GHRP 2 & 6 - HGH PeptidePrice: $297.00 Quantity: Shipping:*FEDEX Ground - $15FEDEX Overnight - $30Refill Total:$0.00Existing Patient Name:*FirstLastDate of Birth: (MM-DD-YYYY)*Email*Update Information (IE. New Address, Phone #, etc)Billing InformationName on card*FirstLastCredit card number*Security Code (CVV)*Expiration (mm/dd/yy)*Type of credit card*VisaMaster CardAmerican ExpressDiscoverNOTE: Before submitting, please make sure your address and contact information are current. Nu Image Medical is not responsible for failed deliveries due to outdated patient information.