ED Med Questionnaire

Let's Get Started!
Let's dive right in and determine if you are new to us or not. If applicable, we will ask you a series of simple medical questions to ensure that ED meds are right for you. Please be sure to answer all questions with a red asterisk (*).

~ Dr. Jason Engel

Do you take nitrates?
(e.g. nitroglycerine for angina or amyl nitrite / "poppers") or do you ever have what could be cardiac related chest pain?*

YesNo
Information on Nitrates & ED Medication

ED medications such as Sildenafil (Viagra) and Tadalafil (Cialis) are contraindicated in the setting of usage of nitrates for cardiac or other conditions.

We can still offer you solutions through our practice at Urologic Surgeons of Washington. Click here for an appointment

Are you requesting a refill?
Only click "yes" if you have seen us within the past year for a consultation and your medical history has not changed.*

YesNo

Let us ask you 8 short medical questions to ensure your eligibility for ED meds and to help you most specifically.

Please tell us your degree of Erectile Dysfunction*

I get erections and can orgasm with masturbation, but I have problems otherwiseI get erections but sometimes can't hold them to orgasm with sexI normally can't orgasm with sex because I lose my erectionI struggle to get an erection at allI never get an erection

Tell us if you have used Erectile Dysfunction medication before*

I have never used ED medications before of any kindI have used pills but had side effectsI have used pills and one was better than the otherI have used pills at their highest strength and they didn't work for meI have used more aggressive medications such as shots in the past
What medication did you take for ED and when, and what happened?

Do you experience premature ejaculation?*

YesNo

Do you have serious cardiovascular (heart) or ophthalmologic (eye) concerns?*

YesNo
What cardiovascular or ophthalmologic concerns do you have?

Do you have absolutely no interest in sex?*

YesNo

Do you have any known drug allergies*

YesNo
What drugs are you allergic to and what happens?

Have you had previous surgery(ies) that you believe have affected your erections*

YesNo
Please list those surgeries that you feel have contributed to ED

Recently, have you experienced fainting, almost fainting, severe headaches, blurry or double vision and/or recurrent nosebleeds?*

YesNo

Now we need to get your demographic and payment information. Please be assured that we will never share any of your information with anyone or solicit you in any way.

Your Name*
Your E-mail*
Mobile Phone Number*
Your Date of Birth (Must be over 21 years of age)*

MonthDayYear

Mailing Address (D.C., Maryland, Virginia Only)*
Your State*
We currently only ship to D.C., Maryland and Virginia

For Refills Only
Name*
Email*
Date Of Birth*

MonthDayYear
Phone Number*
Has your mailing address changed since your last order?*

YesNo
Address (D.C., Virginia, Maryland Only)*

Street Address

Street Address Line 2

CityState

Zip Code

Would you like to receive text messages from us?
We will make sure you received your order on time, remind you about refills, and ask if the medicines are effective. If not effective, we’ll make it easy to see you as a patient in our practice to discuss alternatives. We will absolutely not text you solicitations or share your information with anyone.*

YesNo

Now we need your order.
How Many Pills Would You Like to Order?

30 Tablets Sildenafil (100mg) or Tadalafil (20mg) $12090 Tablets Sildenafil (100mg) or Tadalafil (20mg) $180
Reminder: A typical dose is 50mg Sildenafil or 10mg Tadalafil. Pills are easily cut in half.

Please choose one or more options above and click next to schedule your consultation and free pick-up at our DC Office. Mail-order options are coming soon.

Reminder: A typical dose is 50mg Sildenafil or 10mg Tadalafil. Pills are easily cut in half.

Please choose one or more options above and click next to schedule your consultation and free pick-up at our DC Office. Mail-order options are coming soon.

My Products*

30 Tablets Sildenafil (100mg) or Tadalafil (20mg)

$120.00 Medication TypeQuantity

90 Tablets Sildenafil (100mg) or Tadalafil (20mg)

$180.00 Medication TypeQuantity

Subtotal

$0.00

Shipping

$0.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Final Step & Submission
Thanks for verifying your information. Once you click "submit" below, we will process your order.
Choose Your Consultation Date

MonthDayYear
We will be in touch with you within a few hours to confirm your appointment. Often, we can accommodate your appointment on the same-day as your order.
Should be Empty:

Let's Get Started!

Do you take nitrates?

Information on Nitrates & ED Medication

Are you requesting a refill?

For Refills Only

Would you like to receive text messages from us?

Now we need your order.

Final Step & Submission