Test hipaa_forms_first_name*hipaa_forms_last_namehipaa_forms_email*hipaa_forms_phone*Are you able to complete this form by yourself?*Yes I can complete this form myselfNo, I need some assistanceNo problem! You can call us at our customer assistance number anytime during business hours and we can conduct the evaluation over the phone. Thanks for stopping by! Are you an anatomical male?*YesNo Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920age_calculated Enter your height in feet and inchesFeet*Please enter a number from 4 to 8.Inches*Please enter a number from 0 to 11.height* Enter your weight in pounds (lbs)Weight (lbs)*Please enter a number from 80 to 600.BMI* Are you currently taking any PDE-5 inhibitors like Viagra (sildenafil) or Cialis (tadalafil)?*YesNoPlease tell us which PDE-5 inhibitors (name of drug and dosage) you are currently taking.Please tell us which PDE-5 inhibitors (name of drug and dosage) you are currently taking. Have you been treated for ED in the past?*YesNoPlease tell us about your previous ED treatments and how well they worked for you.Please tell us about your previous ED treatments and how well they worked for you. How do you rate your confidence that you could get and keep an erection?*1 - Very Low2 - Low3 - Moderate4 - High5 - Very High How often are your erections hard enough for penetration?*1 - Almost never or never2 - A few times (much less than half the time)3 - Sometimes (about half the time)4 - Most times (much more than half the time)5 - Almost always or always During sexual intercourse, how often are you able to maintain your erection after you have penetrated your partner?*1 - Almost never or never2 - A few times (much less than half the time)3 - Sometimes (about half the time)4 - Most times (much more than half the time)5 - Almost always or always During sexual intercourse, how difficult is it to maintain your erection to completion of intercourse?*1 - Extremely difficult2 - Very difficult3 - Difficult4 - Slightly difficult5 - Not difficult When you attempt sexual intercourse, how often is it satisfactory for you?*1 - Almost never or never2 - A few times (much less than half the time)3 - Sometimes (about half the time)4 - Most times (much more than half the time)5 - Almost always or alwaysIIEF SCOREiief_score* Do you know your blood pressure (checked in the last 6 months)?*YesNoThat's ok! You can complete your submission now and we will help you find the best option for you to get your blood pressure measured.SystolicDiastolic Check the appropriate boxes to show whether you have, or have ever been diagnosed with, any of the following.* Cardiovascular disease - including Heart attack, arrythmias, coronary artery disease, stroke, aortic stenosis Anatomical penis deformation (Ex. Peyronie disease) Sudden loss of vision Bleeding disorders Severe kidney disease (Ex. dialysis use) Severe liver disease (Ex. Awaiting transplant) Peptic Ulcer Disease Diabetes None of these apply to me Please tell us more about your medical history regarding these conditions.Please tell us more about your medical history regarding these conditions. Are you currently taking any of the following?* Nitrates - including Nitrobid (nitroglycerin), Nitrodur (nitroglycerin patch), Imdur (isosorbide dinatrate), Monokot (isosorbide mononitrate) or any other nitrate? Alpha blockers - including Hytrin (terazosin), Cardura (doxazosin), Flomax (tamsulosin), Uroxatrol (alfuzosin), or any other alpha blockers? Protease inhibitors - HIV antiviral treatments -- anything ending in "-navir" such as Ritonavir Antifungals - including Nizoral (ketoconazole), Sporanox (itraconazole), or other antifungals Oral Erythromycin St. John's Wort L-arginine None of the above Please list the specific medications and the dosages you are prescribedPlease list the specific medications and the dosages you are prescribed Do you have any allergies to medications?*YesNoPlease list your allergies to medications and describe your reactions to each.Please list your allergies to medications and describe your reactions to each. Which of the following apply to you?* I get less than 2 hours of exercise per week I do not eat as heathily as I would like I smoke or use tobacco (e.g., chewing tobacco, snuff, cigarettes) I use other nicotine containing products (e.g. vapes, gum, patches) I drink more than 2 drinks per day I get less than 7 hours of sleep per night on average I am frequently under a lot of stress None of these apply to me Do you have a medical restriction to vigorous exercise or exertion?*YesNoPlease tell us more about your restrictionsPlease tell us more about your restrictions Do you have any other concerns that you would like to discuss with the provider?*YesNoPlease tell us about your concerns.Please tell us about your concerns. Package*Please select the monthly package you prefer. Each of our package subscriptions is priced at $45 per month. You can change your package choice or cancel your subscription at any time.Now & LaterIncludes #10 tablets of sildenafil 20mg and #10 tablets of tadalafil 10mg tablets per month. Provides the immediate impact of fast-acting sildenafil to be ready when the opportunity strikes. Long-acting tadalafil tablets can be used for times when you want to be ready at all times over a longer period of time.On DemandThis package delivers #10 tablets of tadalafil 20 mg per month. Affords the maximum strength dose of the long-acting medication for those times when you know that romance will happen, but you aren’t sure exactly when.Sudden ImpactThis package delivers #10 tablets of sildenafil 100mg per month. For spontaneous interludes, the maximum dose of fast-acting sildenafil will get you ready for when the moment presents itself. Romantic WeekendOur flagship package delivers a convenient, rapid dissolving tablet (RDT) with 50 mg of sildenafil and 10 mg of tadalafil. The medication dissolves in seconds when placed under your tongue. This combo offers the best of both worlds—perfect for those times when you need spontaneity coupled with long lasting power, such as a romantic weekend or honeymoon. Important Stuff!*Important Stuff. Really. Read it. Emergency. Seriously, get help. If you have a medical emergency, dial 911 or contact your physician immediately. The telehealth services we provide are not appropriate in cases of emergency. You’re Not Two-Timing. While we give you convenient access to a healthcare provider and help you get your prescribed medications, our telehealth service is not a substitute for your relationship with your primary care or other physician. Not all medical conditions are appropriate for telehealth services. We are not stepping on anyone’s toes. You Get It. If you complete the questionnaire, access our website, use our application or otherwise use our services, you are letting us know that you have read the “Important Stuff” and the “Terms and Conditions of Use,” and that you understand them and agree to our terms. So, if you use our services, we have a binding agreement. If you don’t agree, don’t use our stuff. No playing dumb. Cancellations. We let you cancel your subscription at any time provided we have not already sent you your medications. Once we send you your prescription, you must pay for it. Your cancellation will be effective to prevent us from sending you any more medicine. If you miss us, you can sign up again later. No Babies. You must be 18 years or older to use our services. Don’t even think about using a fake ID. This is serious stuff. We Can’t Be Everywhere. We can only send medications to persons living in states where we are licensed to do so. Eventually, we may be everywhere, but for right now, we are only licensed in Texas. OUR PACKAGES FOR YOUR PACKAGE We have packaged our telehealth services so you can choose the prescriptions you prefer for your needs. The prescriptions, even the compounds, included in our packages consist of differing portions of Slidenafil® and Tadalafil,® the well-known and trusted medications for ED. The names of our telehealth “packages” give you an idea of the expected results you can achieve for your package. Got it. I've read the Important Stuff and I agree to what it says. CommentsThis field is for validation purposes and should be left unchanged.