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Confidential Patient Contact Form
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Confidential Patient Contact Form
E.D. Patient Contact Form
Fill in our form below and we will contact you back on the next business day to confirm your information and discuss the details necessary to call your physician and request a prescription for Sildenafil on your behalf.
Personal Information
Name
*
First
Last
Date of Birth
*
MM
DD
YYYY
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Best Phone # to Contact You
*
Email
*
Current Prescription Information
Do You Have A Current Viagra® Rx?
*
PLEASE PICK ONE
Yes
No
Either a Brand Rx or a Generic 100mg. or 50mg. rx would be a "yes".
Strength of Current Viagra® Rx?
100mg. Viagra®
50mg. Viagra®
20mg. Sildenafil
Pick your prescribed strength.
Would You Like Us To Transfer Your Rx to Us?
*
Yes
No
Transfer Pharmacy Information
Please provide us with your current pharmacy information so that we can contact them for a transfer of your existing Rx.
Name of Pharmacy to Transfer From?
Transfer Pharmacy Address
Street Address
City
State / Province / Region
Current Physician Information
Please provide us with your current physician so that we can contact them to get you a prescription.
Physician Name
*
First
Last
Physician Phone #
Rx Strength to ask your Physician for?
100mg. Generic Viagra®
20mg. Sildenafil
Submission Section
How Did You Hear About Us?
Other
Radio
Television
Internet Search
Message to Pharmacy
To include a message to us, please type here.
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