Confidential Patient Contact Form

Personal Information

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Best Phone # to Contact You*

Email*

Do You Have A Current Viagra® or Cialis® Rx?*

Either a Brand Rx or a Generic Rx would be a "yes".

Strength of Current Viagra® Rx?

Pick your prescribed strength.

Strength of Current Cialis® Rx?

Would You Like Us To Transfer Your Rx to Us?*

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

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?

How Did You Hear About Us?

Message to Pharmacy

If you would like to send us a message, type it here.

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Comments

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