Sildenafil (Viagra) Tadalafil (Cialis), Avanafil (Stendra) Care Request

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Treatment for erectile dysfunction

Patient Name *

Patient Email Address *

Sex *

Male

Female

Birth Date *

Phone Number *

Address *

City, State, Zip *

Past Medicial Problems (e.g. Asthma - if none, type "none") *

Current Medications (if none, type "none") *

Known Allergies (if none, type "none") *

Are you pregnant? *

Yes

Are you breastfeeding? *

Yes

Reason for Medication (detailed is better) *

Has the patient ever had an allergic reaction to avanafil (Stendra), tadalafil (Cialis), sildenafil (Viagra) or vardenafil (Levitra)? *

Yes

Has the patient ever had an allergic reaction to another erectile dysfunction medication? *

Yes

Is the patient currently using recreational drugs called "poppers" such as amyl nitrate or butyl nitrite? *

Yes

Is the patient currently using a nitrate medication?

Yes

Clear selection

I hereby request *

Tadalafil 10mg (generic Cialis) x 48 tablets @ $75 + $20 physician fee = $95.00

Tadalafil 20mg (generic Cialis) x 48 tablets @ $75 + $20 physician fee = $95.00

Sildenafil 50mg (generic Viagra) x 48 tablets @ $40 + $20 physician fee = $60.00

Sildenafil 100mg (generic Viagra) x 48 tablets @ $40 + $20 physician fee = $60.00

Name (as appears on the credit card) *

Credit Card (Visa/MC), exp. date, CV# *

I hereby confirm that all questions were answered accurately and I hold harmless all medical providers approving or not approving a prescription. I have approached the medical provider myself requesting a specific medication for the purpose listed. I understand that this medicine will be shipped from a licensed pharmacy in India and will take time to arrive due to COVID 19 outbreak. *

I agree

I disagree

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