Client Registration Form

Client Registration Form

Please fill out the following form and complete required payment. Once completed you will be prompted to fill out the medical intake form and someone from our team will contact you during business hours with information about your prescription.
Personal Information

*All Personal Information Strictly Protected by HIPAA*
Full Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Service of Interest *

My Products

Enclomiphene Therapy ( $ 134.15 for each month )

Monthly Subscription for Enclomiphene Therapy

Testosterone Replacement Therapy ( $ 134.15 for each month )

Monthly Subscription for Testosterone Replacement Therapy

Enclomiphene Therapy ( $ 197.90 for each two months )

$98.95/month (25% Discount Billed Bi-monthly) Subscription for Enclomiphene Therapy

Testosterone Replacement Therapy ( $ 197.90 for each two months )

$98.95/month (25% Discount Billed Bi-monthly) Subscription for Testosterone Replacement Therapy

Personal Information