Complete The Form Below To Request A Refill

First Name *

Last Name *

Email *

Phone *

Shipping Address (we will not be responsible for incorrectly entered shipping information) *

City *

State *

Postal code *

Dosages of medications to be refilled *

Would you like pre-loaded syringes, or vials? *

Pre-Loaded Syringes

Vials

Date that the medications are to be shipped: (we can only ship monday-thursday)

Current Weight *

How many lbs have you lost in the last 30 days *

0-3 Lbs

3-6 Lbs

6-9 Lbs

10+ Lbs

How many more lbs do you want to lose? *

Have you had any recent changes to your medical history? *

Do you need a traveling script?

yes

no

Should we use the card on file with your account? (If no, please update payment method below) *

If you have multiple cards on file with us, please enter the last 4 of the card you would like to use:

Name on Credit Card

Credit Card #

CC Expiration Date

CVC (Security code)

Billing Address if different than the shipping address

Do you have any additional questions about your medications that you would like to talk to a provider about? *

Yes, please call me

No, I'm all set

Questions for the staff:

Are you aware of our affiliate program?

Yes, I already know how to get free product

No, Please tell me how to get free product

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Medications you need refilled *

We respond to refill requests Monday - Friday 9 AM-5PM. Weekend or after hours requests will be handled the next business day.