Request Treatment for ED (Erectile Dysfunction)
3 Easy Steps:

1. Fill out Form 
2. Pay via link in your email/text message once order approved (within 24 business hours)
3. Meds Delivered directly to you

Questions: 
- Text 602-607-5094
 - Email us at RX@onthegopharma.com
- Call 602-607-5094. Leave us a message and we will call you back


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Email *
What is your FIRST and LAST name? *
What is your Date of Birth? (Payground, our payment processor, is going to ask for your Date of Birth to make payment )
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Phone number *
Shipping Address: What is your house number and street name? IE. 123 W Main Street APT B *
Shipping Address: City *
Shipping Address: State     *
Shipping Address: Zip Code *
Do you have any allergies? If NO, leave blank
Do you have any health conditions? If NO, leave blank
What is your Primary Care Doctors Name (PCP)?  *
When was your last Doctor's Visit to your PCP?  *
Are you requesting a prescription for anything else? *
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What symptoms are you experiencing? *
How long having you been having the symptoms? *
Have you had any recent hospitalizations or surgeries?  
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Is there anything else you would like your healthcare provider to know?  
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 Consent and Acknowledgment
I consent to receiving telemedicine services and understand the nature of these services.

I acknowledge that my information will be used for the purpose of my telemedicine consultation.
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