Skip to content
(720) 821-6868
Why Trust Us
Prescription Drug Safety
Buying Safely
Help
How It Works
Injection Instructions
How to Administer Injections
Refill
FAQ
Terms & Policies
Your Medical Portal
Cart
Home
Buy Online
Information
Vitamin B12 Injections
Lipotropic Injections
Injection Ingredients
Blog
Contact Us
Search for:
Home
/
ED MIF
ED MIF
Medical Weight Loss Centers of America
2021-08-02T21:25:01+00:00
Contact Information
This information is to verify your current details and is required for prescription purposes.
Name
(Required)
First
Last
Phone
(Required)
(Please provide your most commonly used phone number as we use it to verify your identity)
Email
(Required)
Enter Email
Confirm Email
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
What's the best method to contact you?
Text
Email
Phone
Health Information
Are you allergic to any medication?
What medications or vitamins are you taking?
Height
For Example: 5 ft 05 in OR 5 ft 10 in
Weight
In lbs
What is your date of birth?
MM slash DD slash YYYY
Gender
Male
Female
Do you ever have a problem getting or maintaining an erection that is satisfying enough for sex? If you do not have a problem with an erection, you should not use our service. Which of the following apply to you?
Yes, everytime I want an erection
Yes, sometimes when I want an erection
Yes, rarely when I want an erection
No, never have problems with an erection
Premature ejaculation, coming either before or shortly after sex (penetration) starts, can occur in some men. If this is the only problem you have with sex, you should see a doctor in person and not use our service. Which of the following apply to you?
Only have problems with premature ejaculation. Never have problems with an erection
Have problems with both premature ejaculation and erection
None apply. Do not have premature ejaculation
How did your ED begin? Select the one that best describes your ED.
Began suddenly one night when I could not perform. Has been the same problem ever since
Began gradually and then got worse over time
Do you get erections when masturbating?
Yes
Sometimes
Rarely
No
Do you get erections when asleep or first thing in the morning?
Yes
Sometimes
Rarely
No
Did your ED begin with a new sexual partner?
Yes
No
Enter your blood pressure reading taken within the last 6 months. For Example Systolic 120 / Diastolic 80
Please reenter your blood pressure
Have you had a physical exam by a doctor in the past 5 years? If you have not, we recommend you see a doctor before using our service. Select one of the following:
Yes
No
Did your physical exam include an exam of the genitals (including the testicles, penis)? If you have not, we recommend you see a doctor before using our service. Select one of the following:
Yes, it was normal
No
I did not get a physical exam done from a doctor in the past 5 years
The medicines we prescribe are only appropriate for certain patients. Which of the following best describes your sex drive or desire to have sex (libido)?
I still think about sex and want to have sex. My sex drive or desire to have sex is normal
I do not think about sex or do not want to have sex because I have problems with having an erection
I do not think about sex or do not want to have sex. My sex drive or desire to have sex is abnormal
Other
Over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things?
Not at all
Several days
More than half of the days
Nearly every day
Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?
Not at all
Several days
More than half of the days
Nearly every day
Over the past 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge?
Not at all
Several days
More than half of the days
Nearly every day
Over the past 2 weeks, how often have you been bothered by worrying too much about different things?
Not at all
Several days
More than half of the days
Nearly every day
ED can be related to tobacco, alcohol, or drug use. Select all that apply to you.
Smoke cigarettes or use other tobacco products
Drink more than 2 alcoholic beverages per day
Use a recreational drug called amyl nitrate or butyl nitrite (Poppers, Rush)
Use other recreational drugs
None apply
Some cases of ED are too complex for us to manage effectively online. Instead, you should see a doctor in person and not use our service. Do you have any of these conditions? Select all that apply to you.
Any condition where sex is not advised
Kidney problems including having had a kidney transplant
Liver problems
Neurological problems like multiple sclerosis or motor neuron disease
HIV
Spinal injury or paralysis
Previous surgery on your prostate or pelvis
Radiation therapy to your pelvis
None apply
Some genital issues can cause difficulty with sex and you should see a doctor in person and not use our service. Do you have any of these conditions? Select all that apply to you.
Physical abnormalities of the penis, curving or bending of the penis making it hard for sex, including Peyronie’s disease
Scarring of the penis. Feels like lumps or hard tissue under the skin
Pain with erections
Tight foreskin
None apply
It can be life-threatening to take ED medicines if you now HAVE or HAVE EVER had any of the following heart, blood pressure, or cardiovascular problems. Instead, you should see a doctor in person and not use our service. Select all that apply to you.
High blood pressure
Diabetes
Low blood pressure
Angina
Heart attack
Heart failure
Stroke
History or family history of QT prolongation
Heart arrhythmia
Heart valve problems
Hypertrophic obstructive cardiomyopathy (HCM)
Peripheral vascular disease or claudication
None apply
Certain symptoms can be a sign of a more serious medical problem and you should see a doctor in person and not use our service. When taken with ED medicines, these can cause a life-threatening problem. Select all that apply to you.
Chest pain or shortness of breath when climbing 2 flights of stairs or walking 4 blocks
Chest pain or shortness of breath with sexual activity
Unexplained fainting or dizziness
Cramping of the legs with exercise
Abnormal heartbeats or rhythms
None apply
ED can be the first sign of heart disease. Depending on your risk factors, you may need to see a doctor in person and not use our service. Which of the following additional risk factors do you have for heart disease? Select all that apply to you.
High cholesterol
My father had a heart attack or heart disease at 55 years or younger
My mother had a heart attack or heart disease at 65 years or younger
None apply
It can be life-threatening to take ED medicines if you now have or have ever had any of the following medical conditions. Instead you should see a doctor in person and not use our service. Select all that apply to you.
Priapism (erection lasting longer than 4 hours)
Retinitis pigmentosa
Anterior ischemic optic neuropathy (AION)
Sickle cell disease
Blood clotting disorder, abnormal bleeding or bruising, or coagulopathy
Myeloma or leukemia
Stomach or intestinal ulcer
None apply
It can be life-threatening to take ED medicines if you take any of the following medicines. Instead, you should see a doctor in person and not use our service. Select all that apply to you.
Nitroglycerin spray, ointment, patches or tablets (Nitro-Dur, Nitrolingual, Nitrostat, Nitromist, Nitrolingual, Nitro-Bid, Transderm-Nitro, Nitro-Time, Deponit, Minitran, Nitrek, Nitrodisc, Nitrogard, Nitroglyn, Nitrol ointment, Nitrong, Nitro-Par)
Isosorbide mononitrate or isosorbide dinitrate (Isordil, Dilatrate, Sorbitrate, Imdur, Ismo, Monoket)
Other medicines containing nitrates
Alpha blockers to treat high blood pressure or prostate problems, including doxazosin (Cardura), prazosin (Minipress), alfuzosin (Uroxatral), silodosin (Rapaflo), tamsulosin (Flomax), terazosin (Hytrin)
Sildenafil (Revatio) used to treat pulmonary hypertension
Riociguat (Adempas) used to treat pulmonary hypertension
None apply
Are you allergic to any medicines? Be sure to include any allergies to galactose, phenylalanine, or to any ED medicines, including but not limited to: avanafil (Stendra), sildenafil (Revatio / Viagra), tadalafil (Cialis), and vardenafil (Levitra, Staxyn).
Which of the following prescription ED medicines have you taken in the past, regardless of whether they worked well? SELECT ALL THAT APPLY TO YOU
Never took any prescription ED medicines
Avanafil (Stendra) 50 mg
Avanafil (Stendra) 100 mg
Avanafil (Stendra) 200 mg
Sildenafil (Viagra, Revatio) 25 mg
Sildenafil (Viagra, Revatio) 50 mg
Sildenafil (Viagra, Revatio) 100 mg
Tadalafil (Cialis, Adcirca) 2.5 mg
Tadalafil (Cialis, Adcirca) 5 mg
Tadalafil (Cialis, Adcirca) 10 mg
Tadalafil (Cialis, Adcirca) 20 mg
Vardenafil (Levitra) 2.5 mg
Vardenafil (Levitra) 5 mg
Vardenafil (Levitra) 10 mg
Vardenafil (Levitra) 20 mg
Other
None apply
Of the prescription ED medicines you just told us about, which ones worked to your satisfaction, regardless of whether you are currently taking them? SELECT ALL THAT APPLY TO YOU.
Never took any prescription ED medicines
Avanafil (Stendra) 50 mg
Avanafil (Stendra) 100 mg
Avanafil (Stendra) 200 mg
Sildenafil (Viagra, Revatio) 25 mg
Sildenafil (Viagra, Revatio) 50 mg
Sildenafil (Viagra, Revatio) 100 mg
Tadalafil (Cialis, Adcirca) 2.5 mg
Tadalafil (Cialis, Adcirca) 5 mg
Tadalafil (Cialis, Adcirca) 10 mg
Tadalafil (Cialis, Adcirca) 20 mg
Vardenafil (Levitra) 2.5 mg
Vardenafil (Levitra) 5 mg
Vardenafil (Levitra) 10 mg
Vardenafil (Levitra) 20 mg
Other
None apply
Did you have any side effects from your previous ED medicines that would stop you from using them again?
No, never taken ED medicines before
No, never had side effects that bothered me
Yes
Other than prescription medicines, have you used other treatments for ED in the past?
No, never used other treatments
Yes
Are you currently taking any other prescription medicines for other medical issues? Also include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids.
No, but I understand they are recommended tests
Yes
You can always access your medical record from your account screen. Would you like us to also mail a copy to your doctor?
No
Yes, please mail my medical record to my doctor
Finally, is there anything else we should know?
Hidden
Upload physical check up document
Drop files here or
Select files
Max. file size: 100 MB.
Email
This field is for validation purposes and should be left unchanged.
Close product quick view
×
Go to Top