Prescription Order Form Prescription Order Form "*" indicates required fields Prescription Order FormOffice Name* First Patient Name* First Address* Street Address City State / Province / Region ZIP / Postal Code Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Phone*Allergies* Sermorelin / Ipamorelin6mg / 6mg9mg / 9mgSupplied 6mg Injection Sublingual Supplied 9mg Injection Sublingual QuantityCJC / Ipamorelin6mg / 6mg9mg / 9mgSupplied 6mg Injection Sublingual Supplied 9mg Injection Sublingual QuantitySIG6mg/6mg: 200 mcg sub-Q every day at bedtime9mg/9mg: 300 mcg sub-Q every day at bedtimeSemaglutide / B63mg / 150mg B6/3ml5mg / 250mg B6/5ml10mg / 500mg B6/10mlSupplied 2.5mg Injection Sublingual Supplied 5mg Injection Sublingual Supplied 10mg Injection Sublingual QuantitySIG AOD- 96046mg9mgSupplied 6mg Injection Sublingual Supplied 9mg Injection Sublingual QuantitySIG6mg: 200 mg sub-Q every morning 30-45 minutes before first meal of the day for weight loss9mg: 300 mg sub-Q every morning 30-45 minutes before first meal of the day for weight lossSermorelin/Ipamorelin Oral Solution3mg25mlSupplied 3mg Injection Sublingual QuantitySIG Typical dosing: 0.75ml under tongue twice daily. Do not swallow for two minutes Please specify dosing: SIG Dosing Specification Total Amount Please ask about our other 9,500 compounding formulas TSBOP License #34836 Phone: (682)-325-2410 Toll Free: (833) 859-7267 Fax: 469-253-4142 Affiliated with Physician Name Physician Signature DEA# NPI# Date
