PATIENT INFORMATION

PATIENT NAME
Address

PRESCRIBER INFORMATION

PRESCRIBER NAME

SHIPPING & BILLING

SHIP TO
BILL

RX · SELECT COMPOUND(S) AND COMPLETE SIG / QUANTITY

TISSUE REPAIR & GI HEALTH

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

Injection

Oral Capsule

2.5 mg/mL

500 mcg each

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 10 units subcutaneously before bed

Take 1 capsule by mouth once daily before bed

3 mL vial

90 count

GI HEALTH & IMMUNE SUPPORT

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

Injection

Oral Capsule

2.5 mg/mL

500 mcg each

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 10 units subcutaneously daily

ake 1 capsule by mouth daily

3 mL vial

90 count

GROWTH HORMONE OPTIMIZATION

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

Injection

1 mg / 1 mg / mL

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 10 units subcutaneously in the evening, 5 days on / 2 days off, away from food

2 mL vial

ANTI-AGING & REGENERATIVE

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

Injection

Oral Capsule

Topical

12 mg/mL

4 mg each

3.0% (or custom)

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 10 units subcutaneously 3 times weekly or daily per protocol

Take 1 capsule by mouth daily

Apply topically as directed

2 mL vial

90 count

COGNITIVE & NEUROPROTECTION

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

Injection

Nasal Spray

2.5 mg/mL

7.5 mg/mL

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 10 units subcutaneously once daily in the morning, 5 days per week

1 spray in each nostril once daily in the morning, 5 days per week

3 mL vial

10 mL bottle

ANXIETY RELIEF & COGNITIVE

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

Injection

Nasal Spray

2.5 mg/mL

7.5 mg/mL

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 10 units subcutaneously once daily

1 spray in each nostril once daily in the morning

3 mL vial

10 mL bottle

IMMUNE MODULATION & LONGEVITY

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

Injection

1.5 mg/mL

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 1.5 mg subcutaneously twice weekly

6 mL vial

TISSUE REPAIR & RECOVERY

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

Injection

3 mg/mL

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 300 mcg subcutaneously once daily

3 mL vial

METABOLIC & MITOCHONDRIAL

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

Injection

20 mg/mL

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 2 mg subcutaneously in the morning fasted, 5 days on / 2 days off

2 mL vial

CELLULAR ENERGY & LONGEVITY

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

Injection

Nasal Spray

100 mg/mL

200 mg/mL

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 10 to 50 mg subcutaneously twice weekly

2 sprays in each nostril every morning

3 mL vial

10 mL bottle

SEXUAL WELLNESS & VITALITY

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

Injection

Nasal Spray

5 mg/mL

10 mg/mL

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 2 mg subcutaneously as needed, up to twice weekly, 45 min prior to desired effect

1 spray in each nostril as needed, up to twice weekly, 45 min prior to desired effect

5 mL vial

10 mL bottle

COMBINATION VIALS

COMPOUND

FORMULATION

STRENGTH / CONCENTRATION

COMPOUND

BPC-157 / TB-500

GHK-Cu / BPC-157 / TB-500

GHK-Cu / BPC-157 / TB-500 / KPV

2.5 / 3 mg/mL

12.5 / 2.5 / 3 mg/mL

12.5 / 2.5 / 3 / 2.5 mg/mL

SIG / DIRECTIONS

QTY / PACK

REFILLS

Inject 10 units subcutaneously before bed or as directed

Inject 10 units subcutaneously before bed or as directed

Inject 10 units subcutaneously before bed or as directed

3 mL vial

3 mL vial

3 mL vial

PROVIDER SIGNATURE & ATTESTATION

Attestation: Patient is under my care; order is for a legitimate medical purpose; patient informed of compounded, non-FDA-approved status.

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