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 InformationName* First Last Date of Birth* Month Day Year Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Best Phone # to Contact You*Email* Current Prescription InformationDo You Have A Current Viagra® or Cialis® Rx?*PLEASE PICK ONEYes Viagra®Yes Cialis®NoEither a Brand Rx or a Generic Rx would be a "yes".Strength of Current Viagra® Rx? 100mg. Viagra® 50mg. Viagra® 20mg. Sildenafil Pick your prescribed strength.Strength of Current Cialis® Rx? 20mg. Cialis® 10mg. Cialis® 5mg. Cialis® Would You Like Us To Transfer Your Rx to Us?* Yes No Transfer Pharmacy InformationPlease 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 InformationPlease 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. Generic Cialis® 20mg. Sildenafil Submission SectionHow Did You Hear About Us? Other Radio Television Internet Search Message to PharmacyIf you would like to send us a message, type it here.CAPTCHANameThis field is for validation purposes and should be left unchanged.