First Name _________________________________	Middle Initial _______________________________
Last Name _________________________________	Birthdate* (mm/dd/yy) _______________________________
Address* _________________________________	Apt# _______________________________
City* _________________________________	State* _______________________________
Zip* _________________________________	Country _______________________________
Phone* _________________________________	E-mail* _______________________________

 

Sex: (Circle One)    Male       Female Weight  _________  Lbs

Height ___________   Inches

 

* Please verify these spaces; errors may result in significant delays.

Do you have any known drug allergies? (Circle One)     Yes         No

If yes, please list in the box provided:
_____________________________________________________________________

 ____________________________________________________________

Do you use tobacco products? (Circle One)     Yes         No

If yes, please quantify type of product and usage:
 _____________________________________________________________________

 ____________________________________________________________ 

Do you consume alcohol? (Circle One)     Yes         No
 
If yes, please quantify type of product and usage:
 _____________________________________________________________________

 ____________________________________________________________ 

Do you currently follow a routine exercise program? (Circle One)     Yes         No
 
If yes, please quantify type and amount of exercise:
 _____________________________________________________________________

 ____________________________________________________________ 

ViagraŽ has an absolute contraindication, a condition for which a physician should not give a prescription, in an individual who is taking a medication which contain nitrates. The following is a partial list of medications that contain nitrates. The list is illustrative and not meant to be all-inclusive.

Are you taking any of the following?

Dilarate-Sr Nitrek (transdermal)	Nitrostat
Erythatyl Tetranitrate	Nitro-Bid
Nitrolingal Spray	Imdur
Nitro-Time	Nitro-Par
Ismo	Nitrong
Nitrodisc	Isordil
Nitro-Dur	Nitrol Ointment
Isosorbide Dinitrate	Nitrogard
Transderm-Nitro	Sorbitrate
Isosorbide Mononitrate	Monoket Nitroglyn
Pentaerythritol Tetranitrate	Nitroglycerin
Sodium Nitroprusside	Itraconazole
Erythromycin	Cimetidine
Ketoconazole

 

Are you currently taking any of the above medications or any other medication that contains nitrates?  (Circle One)     Yes         No

If you answered yes, please list in the space provided here:
 _____________________________________________________________________

 ____________________________________________________________

Are you currently taking any medications that have nitro or isosorbide in their names? (Circle One)     Yes         No

If yes, please list:
 _____________________________________________________________________

 ____________________________________________________________

Are you currently taking any other prescription and/or over the counter medication?
(Circle One)     Yes         No

If yes, please explain: For Example: Atenolol 50mg one per day - 5 year history of hypertension (high blood pressure) well controlled with medications, Blood pressure 132/84.
_____________________________________________________________________

 ____________________________________________________________ 

Do you have any of the following medical conditions?
 

Diabetes	Pyronie's Disease
Thyroid Disease	Multiple Myeloma
Leukemia	Claudication
Sickle Cell Anemia	Spinal Cord Injury
Schizophrenia	Benign Prostatic Hypertrophy
Kidney Disease	Prostatic Cancer
Liver Disease	Valvular Heart Disease
Hepatitis

 

Do you have any of the above medical conditions?  (Circle One)     Yes         No

If yes, please explain:
 _____________________________________________________________________

 ____________________________________________________________  

Have you suffered a myocardial infarction, stroke or life threatening arrhythmia within the last 6 years? (Circle One)     Yes         No

If yes, please explain:
_____________________________________________________________________

 ____________________________________________________________  

Do you have a resting hypotension (BP less than 90/50) or hypertension (BP greater than 170/110)? Normal BP is 120/80?  (Circle One)     Yes         No

If yes, please explain:
_____________________________________________________________________

 ____________________________________________________________  

Do you have congestive heart failure or coronary artery disease causing unstable angina (chest pain)?   (Circle One)     Yes         No

If yes, please explain:
_____________________________________________________________________

 ____________________________________________________________  

Do you have Retinitis Pigmentosis?(a minority of these patients have genetic disorders of retinal phosphodiesterase)?   (Circle One)     Yes         No

If yes, please explain:
_____________________________________________________________________

 ____________________________________________________________  

Do you have a history of any other medical condition? (Circle One)     Yes         No

If yes, explain:
_____________________________________________________________________

 ____________________________________________________________  

Have you had any surgeries in the past five (5) years? (Circle One)     Yes         No

If yes, please explain:
_____________________________________________________________________

 ____________________________________________________________  

The following questions are somewhat personal, however, this is the same information that would be requested if you were to visit a clinic with physicians who specialize in erectile dysfunctions.

ViagraŽ is prescribed for the treatment of erectile dysfunction. Do you have difficulties achieving and/or maintaining an erection sufficient for sexual intercourse?
(Circle One)     Yes         No

If yes, please explain:
_____________________________________________________________________

 ____________________________________________________________  

Have you ever been evaluated and subsequently treated for erectile dysfunction?
(Circle One)     Yes         No

If yes, please explain (injection therapy, vacuum pump, penile implant, etc.):
_____________________________________________________________________

 ____________________________________________________________  

You have completed the Medical Questionnaire!

Viagra Order Form

Please take a few minutes to fill in the following information as thoroughly and as accurately as possible. There will be NO charges if your ViagraŽ prescription is not approved. Please fill in all spaces completely. Spaces left blank will only delay your order. If a question does not apply to you please write in N/A (Not Applicable).

Your approved ViagraŽ prescription entitles you to your original order plus (3) additional refills at this time or over the next 6 months. Please check a quantity below to indicate your order. You may also order refills at this time by selecting the quantity that you desire.

50 mg ViagraŽ Tablets

100 mg ViagraŽ Tablets

Best value when 100 mg Tablets are split into two (2) 50 mg doses.

International orders are $46 to ship. If you choose to ship your order outside the U.S., you are assuming all liability for any customs, duties or tariffs. If for some unforeseen reason your order is seized by Customs, we are unable to refund your money. By selecting International shipping, you are agreeing with these terms. Note: International orders please add an additional $28.00 to the above totals (difference between $46.00 - $18.00).
 

If you prefer to pay with a money order please mail payment to the following address:

.

Credit card number* ________________________________	Expiration date* _________________________________
Name (as it appears on card) ________________________________	Billing address _________________________________
Billing city ________________________________	State _________________________________
Zipcode ________________________________	*Please verify these spaces; errors may result in significant delays.

 

Please enter any special instructions:
_____________________________________________________________________

 ____________________________________________________________   

How did you hear about us?
_____________________________________________________________________

 ____________________________________________________________   

By submitting this consultation form:

• I certify that I am 18 years of age or older
• I have read and agree to the Waiver of Liability
• I am legally allowed to receive prescription medication at my shipping address  
• I understand all the side effects of ViagraŽ
• I do not have a current prescription for ViagraŽ from another physician
• I certify that I am allowed by law to use the credit card I have presented
• I understand that my credit card will be billed $75.00 for this consultation, along with my ViagraŽ pill order
• I understand that falsifying information in order to obtain prescription medication is a violation of both state and federal law
• I hereby certify that I have answered all questions truthfully

Signature:_____________________________________  Date:_________________