Refill Request

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

What is the address you'd like to ship to? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I understand that I must be a current patient of Elevation Men's Clinic to request medications and that it will be reviewed. Lab work must be up to date. We may reach out to you to schedule an appointment. *

Yes, I understand.

Are you a current or new patient? *

New Patient

Current Patient

What is the medication you would like to refill? *

Testosterone Cypionate (5 ml)

Tirzepatide/Levocarnitine (2 ml)

Semaglutide/Levocarnitine (4.5 ml)

Tadalafil/Sildenafil Troche with Forest Heights

Lipo-B12

Supplies

Other