Gender-Affirming Treatment Medication Order Form

Gender-Affirming Treatment Medication Order Form
Order gender-affirming treatment medications quickly and easily. Please complete all required fields below to submit your order.
Patient Name
First NameLast Name
Patient Email
example@example.com
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medication Selection
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Estradiol Valerate Injection
Injectable estrogen for gender-affirming therapy.
$60.00QuantityStrength

Testosterone Cypionate Injection
Injectable testosterone for gender-affirming therapy.
$55.00QuantityStrength

Spironolactone Tablets
Oral anti-androgen for gender-affirming therapy.
$30.00QuantityStrength

Finasteride Tablets
Oral medication for androgen suppression.
$25.00QuantityStrength

Total
$0.00
Prescribing Clinician Name
First NameLast Name
Clinic or Practice Name
Preferred Delivery Method
Shipping Address (if shipping selected)
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Special Instructions
Should be Empty: