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Viagra Medical Questionnaire

The following medical history will assist our physicians in deciding whether Viagra® is appropriate for your condition. All information provided will remain secure, confidential and subject to all patient/physician privilege laws. Please take a few minutes to fill in the following information as thoroughly and accurately as possible. Please note there will be a $75.00 consultation fee if the physician determines that Viagra® is appropriate for your condition. Remember that the consultation fee includes three (3) additional refills over the next eighteen (18) months. There will be NO consultation fee if the physician determines that Viagra® is not appropriate for your condition.

Please fill in all fields. Failure to do so will delay your order processing. ALL fields must be completed to submit form. If required field does not pertain to you please type N/A (Not Applicable). Currently our physicians will not prescribe Viagra to individuals under the age of 21 unless there are extenuating circumstances.

Shipping Information

   

 

First Name
 

Middle Initial
 

Last Name
 

Birthdate* (mm/dd/yy)
 

Address*
 

Apt#
 

City*
 

State / Province
 

Zip*
 

Country  

Phone*
 

E-mail*
 

Confirm E-mail address*
 

 
 

 

Sex      

Weight    Lbs

Height    Inches
 

 

* 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:
 


Do you use tobacco products?

If yes, please quantify type of product and usage:
 


Do you consume alcohol?

If yes, please quantify type of product and usage:
 


Do you currently follow a routine exercise program?

If yes, please quantify type and amount of exercise:
 


Viagra® 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

 
 


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:
 


Are you currently taking any medications that have nitro or isosorbide in their names?

If yes, please list:
 


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.
 


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

 
 

Medical Definitions


Do you have any of the above medical conditions?

If yes, please explain:
 

 

Have you suffered a myocardial infarction, stroke or life threatening arrhythmia within the last 6 years?

If yes, please explain:
 

 

Do you have a resting hypotension (low blood pressure) or hypertension (high blood pressure)? Normal BP is 120/80?

If yes, please explain:
 

 

Do you have congestive heart failure or coronary artery disease causing unstable angina (chest pain)?

If yes, please explain:
 


Do you have Retinitis Pigmentosis?(a minority of these patients have genetic disorders of retinal phosphodiesterase)

If yes, please explain:
 


Do you have a history of any other medical condition?

If yes, explain:
 

Have you had any surgeries in the past five years?

If yes, 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.


Viagra® is prescribed for the treatment of erectile dysfunction. Do you have difficulties achieving and/or maintaining an erection sufficient for sexual intercourse?

If yes, please explain:
 


Have you ever been evaluated and subsequently treated for erectile dysfunction?

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

 

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 Viagra® Tablets

100 mg Viagra® Tablets

10 - 100 mg Tablets $119 + $60 Consultation + $18 shipping =

$197

 

20 - 100 mg Tablets $218 + $60 Consultation + $18 shipping =

$296

 

30 - 100 mg Tablets $297 + $60 Consultation + $18 shipping =

$375

 

60 - 100 mg Tablets $540 + $60 Consultation + $18 shipping =

$618

 

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


50 mg Viagra® Tablets

10 - 50 mg Tablets $119 + $60 Consultation + $18 shipping =

$197

 

20 - 50 mg Tablets $218 + $60 Consultation + $18 shipping =

$296

 

30 - 50 mg Tablets $297 + $60 Consultation + $18 shipping =

$375

 

60 - 50 mg Tablets $540 + $60 Consultation + $18 shipping =

$618

 

 

To include a pill splitter with your order please select the box below.

Pill Splitter 

$4.00

 


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Shipping and Handling

Domestic Orders -   Currently there is an $18.00 shipping and handling fee. All orders are shipped via Fed Ex unless shipment is to a PO Box. All PO Box shipments are shipped via USPS Express Mail.

International Shipments -   There is an $48.00 shipping and handling fee. All orders are shipped via Fed Ex.

 

Secure Ordering Process

 

 


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Credit card number*

Expiration Date* (mmyy)
 

Name (as it appears on card)
 

Billing address
 

Billing city
 

State

Zipcode
 

Country       

 

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


Please enter any special instructions:
 


How did you hear about us?     (please be specific)
 


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 Note: We are unable to ship to Michigan.
  • I understand all the side effects of Viagra®.
  • I do not have a current prescription for Viagra® 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 Viagra® 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.
  • 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.


 

This site is not endorsed or affiliated with the company Pfizer. All trademarks and registered trademarks are of their respective companies. Viagra ® is a registered trademark of Pfizer Inc.
Copyright©1viagraonline.com  ALL RIGHTS RESERVED  Viagra is a prescription medicine used to treat erectile dysfunction. Only a physician should decide if it is appropriate for you. These pages are only a summary.
If you have further questions or would like more information about Viagra, consult you personal physician or pharmacist. Information can also be obtained by visiting @ Pfizer  www.viagra.com. or call 1-888-4VIAGRA.

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