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 *

We have partnered with a new 503A/503B compounding pharmacy to improve pricing and supply stability for Tirzepatide. The concentration of your Tirzepatide remains the same; however, you may notice smaller volume in your syringe due to formulation adjustments. Your prescribed dose has not changed. *

I acknowledge that the compounding pharmacy for my Tirzepatide has changed, I understand that the medication concentration and my prescribed dose remain unchanged, even though the injection volume may be smaller

Would you like pre-loaded syringes, or vials? (Retatrutide not available in vials) *

Pre-Loaded Syringes

Vials

Date that the medications are to be shipped: (Shipping is Monday-Thursday)( WE CANNOT SHIP ON WEEKENDS)

Medications you need refilled (all refill requests are subject to provider review and approval) *

Dosage of medications to be refilled (mg) *

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

Payment Type

Credit Card

Care Credit

Cherry

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

Questions for the staff:

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

Any issues related to shipping, delivery, or order contents must be reported within 24 hours of delivery. *

I acknowledge reports made after this time frame may not be eligible for review, or resolution.

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