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Product	Package	QTY	Price	Subtotal

Shipping method	Price

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Enter the phone number to which calls are allowed. The number should include the country and area code, e.g. +1-213-1234455

Important! You will receive an order confirmation to this address.

If you have ordered with us before, please fill in the email address used for the first order and the last 4 digits of the credit card number for your personal information to be filled automatically.
New customer?
Email:	Email
Order ID or Last 4 digits of CC:	Order ID or Last 4 digits of CC
Submit X
First & Last Name:	First name Last name
Address:	Address
City:	City
Zip/Postal Code:	Zip/Postal Code
Country:
State/Province:
Phone:	Phone
Alternative phone no.:	Alternative phone no.
Email:	Email

Payment method:

USDT network:

network:

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	What is MoneyGram?

Call me to remind of reorder:

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Email me a refill reminder:

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Our doctor may need to review your medical condition. Please answer the following questions:

Your Gender:	Male Female
Your Weight and Height:	lb / in kg / cm
Please list any current medical conditions:	None
Please list any prescription, herbal or over the counter medications you are currently taking:	I do not take any other medications
Please list any prescription, herbal or over the counter medications you plan to take while on this program:	I do not plan to take any other medications
Please list all allergies (including medications):	I do not have any allergies
Is there anything else in your medical history you deem relevant:	None
Do you have any of the following conditions: Leukemia, Multiple Myeloma, Sickle Cell Disease, Peptic Ulcers, or Retinitis pigmentosa?	No Yes
Do you take any form of nitroglycerine?	No Yes
We require a valid prescription for your order. Please fax or email it to /	I understand that if a prescription has not been provided, my order will not be processed

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