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Use tab to navigate through the menu items.

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

«Указывая свой номер телефона и отправляя эту форму, вы соглашаетесь получать текстовые сообщения и/или электронные письма от Cerulean Wellness and Recovery, LLC. dba REGNR8Rx относительно хода выполнения вашего заказа».

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CONTACT

REGNR8RX, LLC

3337 NE 33rd Street

Fort Lauderdale, FL 33308

561.527.2339

SALES@REGNR8RX.COM

© COPYRIGHT REGNR8RX 2023

© 2023 REGEN8 RX

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