Product Refill Request


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Product Refill Request

Patient’s Name:

Birth date

Email

Home phone number

- -

Work phone number

- -

Cell phone number

- -

Street Address

Apt#

City

State

Zip Code

Zip Code 2

Credit Card:

Visa

AMEX

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Last Four Digits:

Exp. Date:

Adapt Adrenal Support		Zinc
MegaPolyzyme		L-theanine
Adrenal Rebuilder		5HTP
Panzyme pH		Seriphos
B12methylcobalamin tablets		Probasic Shake
Rejuviflora		B12 Injection Solution
Bio C 1:1 Vitamin C		Cognitive amino capsules
Lacidofil DF		Weight Loss Injection Solution
Omega Pure 600		Profiber
IgG 2000		Rejuvamin
MedCaps DPO		Rejuvamax
MedCaps PMS
Mycelle D3
Ionix Supreme
Thyrodyne
Isaflush
Opticleanse shake
Isafruits

Other. Please list

Your product will be sent out within 24 business hours. Your credit card will be charged for the products plus postage. Please allow 3 to 4 days for mail delivery.

This information is not meant to diagnose, prevent, treat, cure or mitigate any disease. Please see your doctor about any medical problems or you may use this information in discussion with your doctor.