Sildenafil (Viagra) Tadalafil (Cialis), Avanafil (Stendra) Care Request
Treatment for erectile dysfunction
Patient Name *
Patient Email Address *
Sex *
Birth Date *
Phone Number *
Address *
City, State, Zip *
Past Medicial Problems (e.g. Asthma - if none, type "none") *
Current Medications (if none, type "none") *
Known Allergies (if none, type "none") *
Are you pregnant? *
Are you breastfeeding? *
Reason for Medication (detailed is better) *
Has the patient ever had an allergic reaction to avanafil (Stendra), tadalafil (Cialis), sildenafil (Viagra) or vardenafil (Levitra)? *
Has the patient ever had an allergic reaction to another erectile dysfunction medication? *
Is the patient currently using recreational drugs called "poppers" such as amyl nitrate or butyl nitrite? *
Is the patient currently using a nitrate medication?
Clear selection
I hereby request *
Name (as appears on the credit card) *
Credit Card (Visa/MC), exp. date, CV# *
I hereby confirm that all questions were answered accurately and I hold harmless all medical providers approving or not approving a prescription. I have approached the medical provider myself requesting a specific medication for the purpose listed.  I understand that this medicine will be shipped from a licensed pharmacy in India and will take time to arrive due to COVID 19 outbreak. *
Submit
Never submit passwords through Google Forms.
This form was created inside of Infohealth. Report Abuse