Sex       Male Female Weight  100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 144 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251-300 301-350 351-400   Lbs

Height  50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96    Inches

 

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

Do you have any known drug allergies?
yes no
If yes, please list in the box provided:
 

Do you use tobacco products?
yes no
If yes, please quantify type of product and usage:
 

Do you consume alcohol?
yes no
If yes, please quantify type of product and usage:
 

Do you currently follow a routine exercise program?
yes no
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?
yes no
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?
yes no
If yes, please list:
 

Are you currently taking any other prescription and/or over the counter medication?
yes no
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

 

Do you have any of the above medical conditions?
yes no
If yes, please explain:
 

Have you suffered a myocardial infarction, stroke or life threatening arrhythmia within the last 6 years?
yes no
If yes, please explain:
 

Do you have a resting hypotension (low blood pressure) or hypertension (high blood pressure)? Normal BP is 120/80?
yes no
If yes, please explain:
 

Do you have congestive heart failure or coronary artery disease causing unstable angina (chest pain)?
yes no
If yes, please explain:
 

Do you have Retinitis Pigmentosis?(a minority of these patients have genetic disorders of retinal phosphodiesterase)
yes no
If yes, please explain:
 

Do you have a history of any other medical condition?
yes no
If yes, explain:
 

Have you had any surgeries in the past five (5) years?
yes no
If yes, please 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. Generally, our physicians will only prescribe the medication to individuals that have some difficulty in this area. Do you have difficulties achieving and/or maintaining an erection sufficient for sexual intercourse?
yes no
If yes, please explain:
 

Have you ever been evaluated and subsequently treated for erectile dysfunction?
yes no
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

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

50 mg Viagra® Tablets

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

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

Visa MasterCard American Express Discover Card

 

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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.
• 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 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.