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Thank You (ED Form)

Thank you for your purchase, [user_firstname]!

Important information on your next step is below. You are not done yet! We’re getting ready to process your order, but we need you to do one more thing before we can finalize it. We need your medical history!

Your physician will review your medical history within 48 hours and will text you a response.

Fill out the information below to complete your medical history. If you have any questions, please contact us and reference your order number.

Contact Information

This information is to verify your current details and is required for prescription purposes.
Name(Required)
(Please provide your most commonly used phone number as we use it to verify your identity)
Email(Required)
Address(Required)

Health Information

For Example: 5 ft 05 in OR 5 ft 10 in
In lbs
MM slash DD slash YYYY
Gender
ED can be related to tobacco, alcohol, or drug use. Select all that apply to you.
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.
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.
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.
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.
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.
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.
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.
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
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.
Did you have any side effects from your previous ED medicines that would stop you from using them again?
Other than prescription medicines, have you used other treatments for ED in the past?
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.
You can always access your medical record from your account screen. Would you like us to also mail a copy to your doctor?
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