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Name *

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Last

Email *

Government issued ID (for identification purposes) *

Click or drag files to this area to upload. You can upload up to 2 files.

Front and back of current driver license or government issued ID

Phone

What are you interested in? Prices starting at *

• TRT - $249/10 weeks
• HCG + TRT - $399/10 weeks
• Sermorelin - $199/month
• Tirzepatide- $399/mo. (dose dependent)
• Semaglutide - $299/mo. (dose dependent)
• NAD+ - $299/ 10 weeks
• Glutathione - $149/month
• Other

Are you currently receiving TRT, HGH or Peptide therapy?

• Peptides
• TRT
• HGH
• HRT
• none

Select all that apply

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

• Yes
• No

What method of communication do you prefer?

• Phone calls
• Texts
• Email

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