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.
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Sex
Weight Lbs
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Height
Inches
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*
Please verify these spaces; errors
may result in significant delays.
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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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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.
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Are
you taking any of the following?
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Dilarate-Sr
Nitrek (transdermal)
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Nitrostat
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Erythatyl
Tetranitrate
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Nitro-Bid
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Nitrolingal
Spray
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Imdur
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Nitro-Time
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Nitro-Par
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Ismo
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Nitrong
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Nitrodisc
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Isordil
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Nitro-Dur
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Nitrol
Ointment
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Isosorbide
Dinitrate
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Nitrogard
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Transderm-Nitro
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Sorbitrate
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Isosorbide
Mononitrate
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Monoket
Nitroglyn
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Pentaerythritol
Tetranitrate
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Nitroglycerin
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| Sodium
Nitroprusside |
Itraconazole |
| Erythromycin |
Cimetidine |
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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
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Pyronie's
Disease
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Thyroid
Disease
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Multiple
Myeloma
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Leukemia
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Claudication
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Sickle
Cell Anemia
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Spinal
Cord Injury
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Schizophrenia
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Benign
Prostatic Hypertrophy
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Kidney
Disease
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Prostatic
Cancer
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Liver
Disease
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Valvular
Heart Disease
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Hepatitis
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Medical
Definitions
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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:
Have
you had any surgeries in the past five
years?
If yes, 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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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:
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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 Viagra® Tablets
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100
mg Viagra® Tablets
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10
- 100 mg Tablets $119 + $60
Consultation + $18 shipping
=
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$197
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20
- 100 mg Tablets $218 + $60
Consultation + $18 shipping
=
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$296
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30
- 100 mg Tablets $297 + $60
Consultation + $18 shipping
=
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$375
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60
- 100 mg Tablets $540 + $60
Consultation + $18 shipping
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$618
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Best
value when 100 mg Tablets are split
into two (2) 50 mg doses.
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50
mg Viagra® Tablets
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10
- 50 mg Tablets $119 + $60
Consultation + $18 shipping
=
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$197
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20
- 50 mg Tablets $218 + $60
Consultation + $18 shipping
=
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$296
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30
- 50 mg Tablets $297 + $60
Consultation + $18 shipping
=
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$375
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60
- 50 mg Tablets $540 + $60
Consultation + $18 shipping
=
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$618
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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
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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*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 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.
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