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Name *

First

Last

Email *

Phone *

Preferred Method Of Contact

• Text
• Email
• Phone

Preferred Therapy (Prices starting at *

• Testosterone (TRT) - $249 (2.5 month supply @ $99/month)
• Semaglutide Therapy - $299-$399 (Dose dependent)
• HCG + TRT - $349 (2.5 month supply @ $149/month)
• Tirzepatide Therapy - $399-$599 (Dose dependent)
• Sermorelin - $219/month
• Glutathione - $199 (2.5month supply)
• NAD+ Therapy - $249 (2.5month supply)
• Other Options

What are your goals? *

• Improve sex life
• Increase energy & strength
• Gain Muscle Mass
• Lose weight
• Improve Cognative Ability
• Improve sleep & wake up rested
• Increase Quality of Life
• Improve skin tetxure

Select all that apply

Are you currently taking

• Oral Suplements
• Herbal Supplements
• TRT/HRT
• HGH
• Sermorelin
• Other Medications
• Birth Control
• Other Medications
• N/A

Select all that apply

Do you have your own labs? (<60 days)

• Yes
• No

Please provide any additional information you would like to share with us?

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