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Are you the patient in need of medical treatment? *
Yes, I'm the patient in need of treatment.
I'm filling out this consultation on behalf of the patient.
Do you have any condition that may render you incompetent in making sound medical decisions? *
I am capable of making sound medical decisions.
I am UNABLE to make clear and sound medical decisions.
Medical History
Do you have any allergy to a particular medication? *
No known drug allergies.
Yes, I have a history of drug allergies.
If any, list all the medicines you are allergic to.
Do you have any of these conditions? *
Heart disease
Blood disorder (leukemia or myeloma)
Diabetes
Liver or kidney diseases
Low testosterone level
Sickle cell
Deformation of the penis
None of these diseases
Do you have hypertension? *
I have a normal blood pressure or controlled hypertension (<140/90)
I have uncontrolled hypertension (>160/90)
Do you take any of these medications? *
Nitrates, nitroglycerin, isosorbide dinitrate or mononitrate
Terazosin, Doxazosin or Tamsulosin
Alfuzosin or Silodosin
Fluconazole
None of these medications
List all the medications you take, including over-the-counter drugs.
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Which of these medical conditions apply to you? *
Erectile dysfunction
Low libido (lack of interest in sex)
Premature ejaculation
I drink alcohol excessively
I have problems within my relationship
I suffer from depression, anxiety, bipolar, psychosis or other psychiatric disorders
When did your symptoms start? *
Less than SIX months
6-12 months ago
Over a year ago
Symptoms started at a young age (before the age of 21)
What medications have you taken or currently taking for ED?
If applicable, briefly explain your last visit to the doctor for ED.
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Physician Recommended Medication
(No Preference Given)
Sildenafil 20 mg (90 tablets)
Sildenafil (Generic Viagra) 100 mg (30 tablets)
Tadalafil (Generic Cialis) 5 mg (90 tablets)
Tadalafil (Generic Cialis) 20 mg (30 tablets)
Select Medical Consultation Fee (Prescriptions to be charged separately) *
$19.99 - Initial Prescription + 1 refill available
$29.99 - Initial Prescription + 2 refills avialable
$39.99 - Initial Prescription + 5 refills available
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