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BIO HACKING LUXE – PRESCRIPTION REFILL FORM
Thank you for choosing Bio Hacking Luxe.
Please complete this form to request a refill of your prescribed medications.
All information is confidential and HIPAA-protected.
1. Patient Information
First Name
*
Last Name
Phone Number
*
Date of Birth
Email
Age
*
Sex
*
Shipping Address (Street, City, State, Zip):
Preferred Contact Method
*
Preferred Contact Method
A
Call
B
Text
C
Email
D
Whatsapp
*
2. Type of Prescription Refill Requested
Untitled checkboxes field
Hormone Therapy
Peptide Therapy
Injectable Vitamin Therapy
Other
3. Hormone Therapy Refill Selection
Untitled checkboxes field
Estrogen / Estradiol
*
Testosterone Cypionate
DHEA
Progesterone
HCG (Human Chorionic Gonadotropin)
Estrogen Blocker (Anastrozole / Arimidex)
Pregnenolone
Thyroid Support (T3 / T4 or Desiccated Thyroid)
Other
Current Dosage :
Quantity Requested:
Last Injection Date:
4. Peptide Therapy Refill Selection
Please Select All That Apply:
Untitled multiple choice field
A
Retatrutide (Weight Management / Metabolic Reset)
B
Semaglutide (Weight Management / Appetite Control)
C
Tirzepatide (Weight Management / Glucose Optimization)
D
Ipamorelin / CJC-1295 (Growth Hormone Stimulation / Recovery)
E
BPC-157 (Tissue Healing / Gut Repair)
F
TB-500 (Muscle Recovery / Inflammation Reduction)
G
Tesamorelin (Fat Loss / Muscle Definition)
H
GHK-Cu (Skin, Hair, Collagen Support)
I
GHK-Cu with Copper (Skin / Anti-Aging)
J
NAD+ (Energy, Mitochondrial Function, Brain Health)
K
Melanotan II (Tanning Peptide / Libido Support)
L
Oxytocin (Mood, Connection, Libido Enhancement)
M
IGF-1 LR3 (Muscle Growth / Repair)
N
MOTS-C (Mitochondrial Function / Cellular Energy)
O
AOD-9604 (Fat Loss Peptide)
P
Other
Current Dosage :
Quantity Requested:
Last Injection Date:
5. Injectable Vitamin Refill Selection
injectable
A
Vitamin B12 (Energy / Mood / Red Blood Cell Support)
*
B
Lipo-Mino (Fat Burning / Metabolism Boost)
C
Glutathione (Liver Detox / Immunity / Skin Brightening)
D
MICC (Metabolism / Fat Loss Support)
E
CoQ10 (Energy Production / Heart Health)
F
Vitamin D3 (Immunity / Bone Strength / Hormonal Balance)
G
Vitamin C (Immune System / Antioxidant)
H
NAD+ (Cellular Energy / Anti-Aging)
I
Other
Current Dosage :
Quantity Requested:
Last Injection Date:
6. Shipping & Delivery
Delivery Method Preferred
*
Delivery Method Preferred
A
Ship to my address
B
Pick up at clinic
Preferred Delivery Date
*
7. Health & Safety Confirmation
Untitled multiple choice field
A
I confirm I am requesting a refill for a medication previously prescribed by Bio Hacking Luxe.
*
B
I confirm that my health condition and medications have not changed since my last consultation.
C
I acknowledge that I am responsible for the safe storage and proper administration of all medications.
D
I understand that my refill request will be reviewed by a licensed medical provider before approval.
8. Consent & Signature
Electronic Signature
Signature
*
Date
*
