Refill Form Start Your Refill If you have any questions on this please contact us at 406.201.9378. Thank you! Please enable JavaScript in your browser to complete this form.Date *Name *FirstLastEmail *Phone *Are you refilling a GLP-1? *YesNo as confirm is Please choose GLP-1 refill:SemaglutideTirzepatideHow many units are you currently injecting per week? (If you are splitting your dose into two injections per week please add the two together and mark the full amount per week you are injecting):Other Refills (If you are interested in trying one of these for the first time please contact us first):Glutathione ($199 10ml)NAD+ Vial ($499 10ml)B12 ($150 10ml)MIC B12 ($199 10ml)LDN (low dose naltrexone) 1.5mgLDN (low dose naltrexone) 3mgLDN (low dose naltrexone) 4.5mgSermorelinZofran ($25 if not on membership)By checking yes you confirm your understanding that payment is required upfront to fill your prescription. If on a GLP-1 Membership please check "Membership" as your billing is monthly. *YesMembershipSubmit
