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Date
Date Format: MM slash DD slash YYYY
Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Email
Enter Email Confirm Email
Phone
Drivers License Number
State
Which Medications do you want to reorder.*
Note: If a medication is outside of your already approved protocol you will need to schedule a consultation before we can send any new medication. ALSO: It is required that your lab results be less than 6 months old at all times. Please schedule labs prior to refill order if needed!
Shipping Address
***We cannot ship to a PO Box - we need an actual street address in order to ship your medication. ***

Street Address Address Line 2 City State ZIP Code
Is your shipping address the same as billing address?
- Yes
- No
Billing Address
Street Address Address Line 2 City State ZIP Code
Cardholder's Name
Credit Card
Card Type
- American Express
- Discover
- Mastercard
- Visa
- HSA
Expiration Date
Expiration Year
Security Code

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