Mens Health ED

1
Which State Do You Live In?* This field is required.
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2
Are You Male And Aged Between 18 - 85?* This field is required.
YESNO
3
Warning - You must be at least 18 to order

Your order will not be processed
4
How Often Do You Have Difficulty With Erections?* This field is required.
Always
Sometimes
Rarely
5
Have You Had A Physical Exam From Your Physician In The Last 3 Years* This field is required.
YESNO
6
What Was Your Last Blood Pressure Systolic Reading?* This field is required.Your Systolic Number (The Top Number)
Less Than 90
90 - 109
110 - 140 (Normal)
141 - 160
Greater Than 160
7
Warning - Your Blood Pressure is outside of acceptable range, please consult a physician.

Your order will not be processed
8
What Was Your Last Blood Pressure Diastolic Number * This field is required.Your Last Diastolic Number (The Bottom Number)
Less Than 60
60 - 69
70 - 85 (Normal)
86 - 95
Greater Than 95
9
Warning - Your Blood Pressure is outside of acceptable range, please consult a physician.

Your order will not be processed
10
Have You Taken Viagra®, Levitra® or Cialis® at least twice previously without any serious side effect?* This field is required.
YES
NO
11
Do You Smoke?* This field is required.
YESNO
12
WARNING - Smoking is likely to make erectile problems much worse. We recommend stopping to help your problems. See the following information from the CDC: https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/index.html
13
In The Last Year, Have You Had More Than 5 Drinks In A Day On 1 Or More Occasions?* This field is required.
YESNO
14
WARNING - Alcohol can contribute to ED. You may wish to check this material from the CDC: https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm
15
Do You Have An Allergy (Hypersensitivity) Or Had Any Adverse Reactions To Any Medications?* This field is required.
YESNO
16
Please List All Medications That You Are Allergic ToPlease the space below
17
Has Your Physician Advised You To Avoid Sex Or Strenuous Physical Activity* This field is required.
YESNO
18
WARNING - It is not advisable to use this medication if your physician has advised you to avoid sex or strenuous physical activity

Your order will not be processed
19
Do You Have Difficult Or Labored Breathing, Or Any Discomfort / Pain In Your Chest With Light Or Moderate Physical Activity, Such As Walking Briskly For 20 Minutes Or Climbing Two Flights Of Stairs?* This field is required.
YESNO
20
WARNING - It is not advisable to use this medication if you have difficult or labored breathing, any pain in your chest or have problems with moderate physical activity, such as walking briskly for 20 minutes or climbing two flights of stairs

Your order will not be processed
21
Have You Had A Heart Attack Or Stroke / TIA (Transient Ischaemic Attack) or Mini Stroke? * This field is required.
YESNO
22
WARNING - ED Medications are not recommended if you have suffered from these conditions

Your order will not be processed
23
Do You Have A Problem With:* This field is required.Uncontrolled High Blood Pressure? Low Blood Pressure? Any Heart Problems now or in the past that you have been treated for?
YESNO
24
WARNING - ED Medications are not recommended if you have suffered from these conditions

Your order will not be processed
25
Do You Have Or Are You Under A Physician Care For Angina (Chest Pain), Irregular Heart Beat Or Palpitations (Arrhythmia)* This field is required.
YESNO
26
WARNING - ED Medications are not recommended if you have suffered from these conditions

Your order will not be processed
27
Have You Ever Suffered From ANY Of The Following Conditions:* This field is required.Peyronie’s disease or any other deformation of the penis? Loss of vision because of damage to the optic nerve (such as non-arteritic anterior ischemic optic neuropathy [NAION]) or have an inherited eye disease (such as retinitis pigmentosa)? Galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption? Hepatic (liver) disease (including cirrhosis of the liver) Renal (kidney) impairment? Blood problems such as sickle cell anemia, multiple myeloma or leukemia? Any bleeding issues (e.g. hemophilia) or have active stomach ulcer?
YESNO
28
WARNING - ED Medications are not recommended if you have suffered from these conditions

Your order will not be processed
29
Are There Any Operations Or Illnesses That You Have Currently Or Have Had Previously? This Will Help The Prescriber In Deciding On A Prescription Suitable For You.* This field is required.
YESNO
30
Please Provide Details
31
Are You Currently Taking Any Medications (including over the counter, prescription or recreational drugs)?* This field is required.
YESNO
32
Are You Taking Any Of The Following Medications? * This field is required.Nitrates (nicorandil or other nitric oxide donors e.g. glyceryl trinitrate, isosorbide mononitrate or dinitrate, nicorandil?Any alpha-blockers, such as Tamsulosin (Flomax), alfuzosin, or doxazosin (usually for enlarged prostate (benign prostatic hyperplasia) or to treat high blood pressure?Anticoagulants e.g. warfarin (Coumadin), rivaroxaban (Xarelto), dabigatran (Pradaxa), apixaban (Eliquis), clopidogrel (Plavix)or related drugs?Drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)?Any CYP3A4 inhibitors, e.g. Cobicistat containing products for HIV infection: Genvoya, Stribild, Symtuza, Prezcobix and Evotaz. Ritonivir (for HIV), Itraconazole or ketoconazole (to treat fungal infections), erythromycin, Clarithromycin (antibiotics), diltiazem?
YESNO
33
WARNING - ED Medications are not recommended if you have suffered from these conditions

Your order will not be processed
34
Please Let Us Know Of Any Other Medication You Are Taking* This field is required.Please include medication name, strength and how often you take it for each medication you are taking
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Large
Normal
Small
Ok
Ok
35
Is There Anything You Wish To Ask The Prescriber Or Would Like To Inform The Prescriber About? * This field is required.
YESNO
36
Please List Anything You Want To Communicate To The Prescriber
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Large
Normal
Small
Ok
Ok
37
YOUR TREATMENT OPTIONS* This field is required.Please Select Medication/Quantity and Enter Payment Method
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My Bag
0
My Bag
Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costUSD
Sildenafil 100mg (Generic Viagra®) 15 ct
$60.00Edit
Back
Sildenafil 100mg (Generic Viagra®) 30 ct
$105.00Edit
Back
Sildenafil 100mg (Generic Viagra®) 60 ct
$180.00Edit
Back
Sildenafil 100mg (Generic Viagra®) 90 ctBEST VALUE @ $2.50 PER PILL
$225.00Edit
Back
Tadalafil 20mg (Generic Cialis®) 15 ct
$75.00Edit
Back
Tadalafil 20mg (Generic Cialis®) 30 ct
$120.00Edit
Back
Tadalafil 20mg (Generic Cialis®) 60 ctBEST VALUE @ $3.50 PER PILL
$210.00Edit
Back
Total cost $0.00
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38
Patient Information* This field is required.
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39
Please Select Your Date Of Birth* This field is required.
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40
Agreement* This field is required.You agree to the following: The treatment is solely for your own use. You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health. You will read the patient information leaflet supplied with your medication. You will notify your primary care physician about your treatment from Liquivida TeleHealth. You also agree to have Liquivida send you occasional offers and information via email or SMS. In case of any adverse affects or any medical emergencies please contact your physician or go to your nearest emergency room.
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41
Please Upload A Picture Of Your Current State Issued ID (front only)* This field is required.To legally provide your medication, it’s essential for us to use a two-step verification process, which includes a government-issued photo ID You only need to verify your ID with us once. Unreadable ID Images will delay your order. Please make sure that all information is visible. Only .jpg or .png files will be accepted.
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