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Viagra Online

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Viagra Medical Questionnaire

The following medical history will assist our physicians in deciding whether ViagraŽ 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 ViagraŽ 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 ViagraŽ 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:
 


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

 
 


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.


ViagraŽ 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 ViagraŽ Tablets

100 mg ViagraŽ 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 ViagraŽ 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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