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Sex
Weight
Lbs |
Height
Inches
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* Please verify these spaces; errors may result in significant delays. |
Do you have any known drug allergies?
If yes, please list in the box provided:
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Do you use tobacco products?
If yes, please quantify type of product and usage:
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Do you consume alcohol?
If yes, please quantify type of product and usage:
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Do you currently follow a routine exercise program?
If yes, please quantify type and amount of
exercise:
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ViagraŽ
is contraindicated in
individuals who are currently taking or have a
history of taking any 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 |
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Are you currently taking any of the above medications or any other medication that contains nitrates?
If you answered yes, please list in the space provided here:
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Are you currently taking any medications that have nitro or isosorbide in their names?
If yes, please list:
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Are you currently taking any other prescription and/or over the counter medication?
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.
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Do you have any of the following medical conditions?
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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 |
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Medical Definitions |
Do you have any of the above medical conditions?
If yes, please explain:
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Have you suffered a myocardial infarction, stroke or life threatening arrhythmia within the last 6 years?
If yes, please explain:
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Do you have a resting hypotension
(low blood pressure) or hypertension (high blood
pressure)? Normal BP is 120/80?
If yes, please explain:
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Do you have congestive heart failure or coronary artery disease causing unstable angina (chest pain)?
If yes, please explain:
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Do you have Retinitis Pigmentosis?(a minority of these patients have genetic disorders of retinal
phosphodiesterase)
If yes, please explain:
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Do you have a history of any other medical condition?
If yes, explain:
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Have you had any surgeries in the past five (5) years?
If yes, please explain:
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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.
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ViagraŽ is prescribed for the treatment of erectile dysfunction. Generally, our physicians will only prescribe the medication to individuals that have some difficulty in this area. Do you have difficulties achieving and/or maintaining an
erection sufficient for sexual intercourse?
If yes, please explain:
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Have you ever been evaluated and subsequently treated for erectile
dysfunction?
If yes, please explain (injection therapy, vacuum pump, penile implant, etc.):
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Our
physician suggest purchasing the 100mg dose
and then splitting the tablets in half with a pill
splitter, in order to provide (2) 50mg doses (50mg
is the recommended dose for most individuals).100
mg ViagraŽ Tablets
100 mg ViagraŽ Tablets
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10 - 100 mg Tablets +
FREE Consultation + FREE shipping = |
$169 |
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20 - 100 mg Tablets +
FREE Consultation + FREE shipping = |
$289 |
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30 - 100 mg Tablets +
FREE Consultation + FREE shipping = |
$399 |
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60 - 100 mg Tablets +
FREE Consultation +
FREE shipping = |
$775 |
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Best value when 100 mg Tablets are split into two (2) 50 mg doses. |
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To include a pill splitter
with your order please select the box below.
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Shipping
and Handling
Domestic Orders - Currently shipping
and handling fee for courier service is FREE.
International
Shipments - There is a $48.00
shipping and handling fee.
Secure Ordering Process
Click
on the image for more info |
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*Please verify these spaces; errors may result in significant delays.
Please enter any special instructions:
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How did you hear about us?
(please be specific)
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By submitting this consultation form:
- I certify that I am 21 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 certify that I have had a complete
physical in the past two years.
- 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.
- I
understand that there are no returns or refunds
for any orders due
to the fact that this is a prescription
medication.
Please review all information before submitting form so that your order will not be delayed. |
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