Refill Form

Start Your Refill

If you have any questions on this please contact us at 406.201.9378. Thank you!

Date *

Name *

First

Last

Email *

Phone *

Are you refilling a GLP-1? *

• Yes
• No

dose injecting): Name

Please choose GLP-1 refill:

• Semaglutide
• Tirzepatide

How 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:

• Glutathione ($199 10ml) tv
• NAD+ 1000mg Vial: 30% off for May (originally, $399, only $279.30)
• B12 ($150 10ml) tv
• Fat Burner / LIPO-C+ ($199) tv
• LDN (low dose naltrexone) 1.5mg
• LDN (low dose naltrexone) 3mg
• LDN (low dose naltrexone) 4.5mg
• Sermorelin (tv)
• Zofran ($25 if not on membership)

(If you are a Metabolic Health Member, all take home vials "tv" are 15% off always for you):

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. *

• Yes
• Membership

Notes:

Submit