Peptide Order Request Form

PEPTIDES BY VIAL*

BPC-157 | 5 mg | 1 Vial * BPC-157 | 5 mg | 5 Vials BPC-157 | 5 mg | 10 Vials Thymosin Beta-4 | 10 mg | 1 Vial Thymosin Beta-4 | 10 mg | 5 Vials Thymosin Beta-4 | 10 mg | 10 Vials CJC-1295 | 5 mg | 1 Vial CJC-1295 | 5 mg | 5 Vials CJC-1295 | 5 mg | 10 Vials PT-141 | 10 mg | 1 Vial PT-141 | 10 mg | 5 Vials PT-141 | 10 mg | 10 Vials GHK-Cu | 50 mg | 1 Vial GHK-Cu | 50 mg | 5 Vials GHK-Cu | 50 mg | 10 Vials Ipamorelin | 5 mg | 1 Vial Ipamorelin | 5 mg | 5 Vials Ipamorelin | 5 mg | 10 Vials Tesamorelin | 10 mg | 1 Vial Tesamorelin | 10 mg | 5 Vials Tesamorelin | 10 mg | 10 Vials MOTS-c | 5 mg | 1 Vial MOTS-c | 5 mg | 5 Vials MOTS-c | 5 mg | 10 Vials Cerebrolysin | 10 ml | 1 Amp Cerebrolysin | 50 ml | 5 Amps Cerebrolysin | 100 ml | 10 Amps None

*Includes mixing agents, instructions, and all necessary supplies.

Peptides by Spray*

Semax | 750 mcg | 60 Sprays * Selank | 750 mcg | 60 Sprays None

Do you require doctor prescription and medical documents?*

Yes No

Passport Upload* Max 1 File Size 5MB or Less

Upload Passport ID Page

Age*

I'm sorry, these products and services are not available to those age 20 and less.

First Name*

Last Name*

Email Address*

Gender*

Male Female Other

Date of Birth*

Height cm*

Weight kg*

Medical History*

Have you been diagnosed with disease?*

Yes No

Please List All Diagnosed Diseases by Year*

Do you take medicine everyday?*

Yes No

Please List All Current Medications*

Do you have Food or Drug Allergy?*

Yes No

Please List All Food and Drug Allergies*

Payment Method*

Bank Transfer Credit Card

Shipping Address*

phone number*

I confirm that the information provided is true and accurate. All orders are reviewed by the medical team before authorization. I authorize FRESH GENETIQ to process my order through its licensed provider network.*

*Write Your Signature

ORDER
REQUEST

ORDER REQUEST

I'm sorry, these products and services are not available to those age 20 and less.

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