GoRocky Order Form

Health History 👨‍⚕️
Please answer the following questions to the best of your knowledge to get approved by our doctors and receive your free prescription upon delivery of the medication.
Product ID
Age Verification*
Please enter your age to confirm you're 18 or older.
Have you had trouble having and/or maintaining an erection in the last 6 months or longer?*

YesNo
Have you gone to the doctor or taken medication for Erectile Dysfunction (ED) previously?*
Kindly choose the conditions that apply to you. Choose as many as apply*

I have chest pain or shortness of breath.I have kidney, liver, lung, and/or neurological problems.I am taking other medication or supplements not listed beforeNone of the above
If "None of the above" is selected, kindly ensure that no other options are selected
You must be over the age of 18 to consume this medicine
Temp Condition

THANK YOU FOR COMPLETING THE ASSESSMENT ! 🥳

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Health History 👨‍⚕️