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Confidential Patient Form
FAQs-Prescribers
About Us
Confidential Patient Contact Form
E.D. Patient Contact Form
Fill in our form below and we will contact you back on the next business day to confirm your information and discuss the details necessary to call your physician and request a prescription for Sildenafil on your behalf.
Personal Information
Name
*
First
Last
Date of Birth
*
Month
Day
Year
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Best Phone # to Contact You
*
Email
*
Current Prescription Information
Do You Have A Current Viagra® or Cialis® Rx?
*
PLEASE PICK ONE
Yes Viagra®
Yes Cialis®
No
Either a Brand Rx or a Generic Rx would be a "yes".
Strength of Current Viagra® Rx?
100mg. Viagra®
50mg. Viagra®
20mg. Sildenafil
Pick your prescribed strength.
Strength of Current Cialis® Rx?
20mg. Cialis®
10mg. Cialis®
5mg. Cialis®
Would You Like Us To Transfer Your Rx to Us?
*
Yes
No
Transfer Pharmacy Information
Please provide us with your current pharmacy information so that we can contact them for a transfer of your existing Rx.
Name of Pharmacy to Transfer From?
Transfer Pharmacy Address
Street Address
City
State / Province / Region
Current Physician Information
Please provide us with your current physician so that we can contact them to get you a prescription.
Physician Name
*
First
Last
Physician Phone #
Rx Strength to ask your Physician for?
100mg. Generic Viagra®
20mg. Generic Cialis®
20mg. Sildenafil
Submission Section
How Did You Hear About Us?
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Internet Search
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