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Please fill out the following form
in order to start your Telehealth Consultation

First name

Last name

Email

Date of Birth

Street Address

City

Region/State/Province

Postal / Zip code

Phone

Biological sex at birth?

CURRET WEIGHT *

100 - 150 lbs

150 - 200 lbs

200 - 250 lbs

250 - 300 lbs

300 lbs +

How tall are you?* Example: 6' 2"

WHAT ARE YOU GOALS?

WEIGHT LOSS

ENERGY

PERFORMANCE

IMMUNE BOOST

SKIN CARE

GENERAL WELLNESS

SEXUAL WELLNESS

OTHER

Do you have any ofth following medial conditions?

Type 2 Diabetes

High Blood Pressure

High Cholesterol

Cancer

Stroke or Seizure

Liver or Kidney Issues

Heart Problems

Thyroid Issues

Other*

None of the Above

*If "Other" Please Describe

Any Alergies that you are aware of?

Prescription Medications OR Non-Prescription Supplements you are currently taking:*

Desired Medication / Peptide / Vitamin

Tirzepatide/B6

NAD+

NMN

Sermorelin Peptide

SKIN Revive®

Vitamin B12

Vitamin D

Vitamin C

PT-141

BPC-157

Ipamorelin

Referred By

Discount Code:

SIGNATURE. I HAVE READ THE CONSENT TO TREATMENT BELOW. (First and Last Name)*

Date (mm/dd/yyyy):

I agree that the information I provide is accurate

“By providing your phone number and submitting this form you agree to receive text messages and/or emails from Cerulean Wellness and Recovery, LLC. dba REGNR8Rx regarding the progress of your order."

CONTACT

REGNR8RX, LLC

3337 NE 33rd Street

Fort Lauderdale, FL 33308

561.527.2339

SALES@REGNR8RX.COM

© COPYRIGHT REGNR8RX 2023

© 2023 by REGEN8 RX

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