Testosterone Refill Request
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NAME  *
DATE OF BIRTH  *
PHONE NUMBER *
EMAIL  *
ADDRESS *
Do you need a refill on alcohol wipes?  *
TESTOSTERONE DOSAGE  (ex. 120mg or 60 units) *
WEEKLY OR BIWEEKLY INJECTION? *
INTRAMUSCULAR OR SUBCUTANEOUS INJECTION? *
SITE OF INJECTION?  *
If you have a specific syringe size, specify below. 
(Leave blank if unsure)
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If you have a specific needle length for thigh or deltoid, specify below. 
(Leave blank if unsure)
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