$49.00 Fill out a health history form so the doctor can review your request and submit the prescription. $ Name * Address * Phone * Date of Birth * Drug Allergies * Have you Used ED Medication Previously? * Yes No Name/Phone of Primary Care Physician * Do you have issues with either obtaining or maintaining an erection that is satisfying enough for sex? * Yes, every time Yes, sometimes No, not an issue Please Check any medications that you have tried previously to treat erectile dysfunction * Viagra Cialis Levitra Staxyn Stendra Intraurethral-Suppository Penile Pump Penile Implant Shockwave Therapy List Each treatment tried and it's effectiveness / side effects * List any medications and supplements and how you take them * Do you take any of the following medications Nitrates (Nitroglycerin) Alpha Blockers (Isosorbide) No Do you have any medical conditions or history of surgeries? Do you have a history of the following: Check if Yes * Hypotension (Low BP) Fainting Poorly Controlled Hypertension (Hight BP) ANGINA (Chest Pain) Heart Attack, Stroke or TIA (Mini Stroke) in the last 6 months irregular heat rate claudication (leg pain with exercise) Migraines with exertion Difficulty breathing when rapidly climbing 2 flights of stairs I have NONE of the above medical issues Do you have anxiety or depression? * Yes No Have you had a genital exam in the last 5 years? * Yes No Any other medical conditions that we should be made aware of? * Date Get Your Viagra/Cialis quantity Add to cart Buy with Reviews (0) Reviews There are no reviews yet. Be the first to review “Get Your Viagra/Cialis” Cancel replyYour email address will not be published. Required fields are marked *Your rating * Rate… Perfect Good Average Not that bad Very poor Your review *Name * Email * Save my name, email, and website in this browser for the next time I comment.
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