First Name *

Last Name *

Date of birth *

Phone *

Email *

What medication are you requesting? *

Testosterone Cypionate

Enclomiphene

All medications are sourced from 503A USA pharmacies.

Have there been any changes to your health history? *

Yes

Membership status? *

Would you like to learn more about peptides?

Yes

Any changes to your home address? If yes, please provide updated address below. *

Yes

Address

Street Address

City

State

Country

Postal Code

Upload your valid State ID below: *

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By signing below, I acknowledge and certify that the information provided is true and accurate and that I am the patient requesting this refill. I understand that submission of this request does not guarantee prescription approval and that additional medication evaluation, laboratory testing, or a telehealth consultation may be required at the provider's discretion. If a telehealth consultation is required, I authorize the associated $49 consultation fee (N/A to members). I agree to notify Elite Integrated Performance of any changes to my health or medications since my last visit.

HIPPA Acknowledgement: I understand that the PHI I submit through this form will be used by Elite Integrated Performance and its authorized healthcare providers to evaluate and process my prescription refill in accordance with applicable privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA).

Signature (Required): *

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By checking this box, I consent to receive non-marketing text messages from Elite Integrated Performance about your medical care, or RX refill form. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from Elite Integrated Performance at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.