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*Clinic Name

*Patient Name:

*Patient Address:

*Patient Phone:

*Patient City:

*Patient State:

*Patient Zip:

*Patient Email:

IS PATIENT CURRENTLY ON A FIXED INCOME?

Patient DOB:

Apptrim (#120) - Obesity

Number of Bottles:

Special Requests:

AppTrim-D (#120) - Obesity/Sleep Disorders

Number of Bottles:

Special Requests:

Gabadone (#60) - Sleep Disorders/Anxiety

Number of Bottles:

Special Requests:

Hypertensa (#90) - Hypertension

Number of Bottles:

Special Requests:

Sentra AM (#60) - Fatigue & PTSD

Number of Bottles:

Special Requests:

Sentra PM (#60) - Sleep Disorders/Depression

Number of Bottles:

Special Requests:

Theramine (#60) - Pain & Infammation

Number of Bottles:

Special Requests:

Theramine (#120) - Pain & Infammation

Number of Bottles:

Special Requests:

Lister V (#60) - Viral Infections

Number of Bottles:

Special Requests:

Trepadone (#90) - Joint Pain & Osteoarthrits

Number of Bottles:

Special Requests:

Trepadone (#120) - Joint Pain & Osteoarthrits

Number of Bottles:

Special Requests:

Percura (#120) - Peripheral Neuropathy

Number of Bottles:

Special Requests:

Notes:

Special Requests:

Your Signature:

*Spam Stopper (enter a primary color):