ED Intake Form

1
What is your full name?* This field is required.
First Name
Last Name
2
What is your date of birth?* This field is required.
Date
Year
Month
Day
3
What is your full address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
What is your phone number?* This field is required.
Please enter a valid phone number.
5
What is your email?* This field is required.
example@example.com
6
Please upload a picture of your government issued ID* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
7
What gender were you assigned at birth?* This field is required.
Male
Female
8
What symptoms of ED are you experiencing?* This field is required.
Difficulty getting an erection
Difficulty maintaining an erection
Ejaculate too quickly
Other
9
What symptoms are you experiencing?
10
When do these symptoms occur?* This field is required.
Every time I engage in sexual activity
When I am with a new partner
When I drink alcohol
When I am anxious or stressed
11
Do you experience morning erections?* This field is required.
Yes
Rarely or never
Sometimes
12
Have you undergone blood tests within the past 2 years to screen for diabetes or low testosterone?
Yes
No
13
Was your lab work normal?
Yes
No
14
Unfortunately based on your answers, we are unable to provide you with a prescription. We feel you are best suited to receive the pescription from your primary care provider where you may require more frequent monitoring. Thank you for using our form!
15
What is your most recent blood pressure reading?* This field is required.
Normal (120/80)
High (130/80)
Low (110/80 or Lower)
I'm not sure what my blood pressure reading is
16
Unfortunately based on your answers, we are unable to provide you with a prescription. We feel you are best suited to receive the pescription from your primary care provider where you may require more frequent monitoring. Thank you for using our form!
17
We do require a recent blood pressure reading to be able to provie you with a prescription. Please obtain a blood pressure reading and re-submit your form. Thank you!
18
Do you have any of the following Medial Conditions?* This field is required.
Chest pain or shortness of breath
Irregular heart rate, heart rhythm disorders, or a congenital prolongation of the QT interval
Uncontrolled Diabetes or irregular blood sugar levels
Eye or vision problems
Low Blood Pressure
Pain when you have an erection
Peyronie's disease
Prostate problems
Testosterone deficiency
Using nitroglycerin, isosorbide, or any other nitrate medicine
Stroke or Transient Ischemic Attack (TIA)
Spinal problems
Passing out or fainting
Heart attack, chest pain, or angina
Condition where you've been told sex is not recommended
None of these apply to me
19
Unfortunately based on your answers, we are unable to provide you with a prescription. We feel you are best suited to receive the pescription from your primary care provider where you may require more frequent monitoring. Thank you for using our form!
20
Do you have any allergies to medications?* This field is required.
YESNO
21
What medications are you allergic to?
22
Do you take any prescription, over the counter or herbal medications?* This field is required.
YESNO
23
What prescription, over the counter or herbal medications do you take?
24
Do you have any medical conditions?* This field is required.
YESNO
25
What medical conditions do you have?
26
What dosage form best suits your need?* This field is required.
Oral Tablets: Oral tablets can take 1-2 hours to achieve maximum effect. Traditional dosage form.
QuickStrips: Novel dosage form that rapidly dissolves under or on your tongue allowing them to work in 10-15 minutes, making them 6 times quicker than traditional tablets
27
Which active ingredient best suits your needs?* This field is required.
Sildenafil: The active ingredient in Viagra. Oral tablets take about 1 hour to achieve maximum effect and can last up to 4-6 hours. Recommended for those with a more predictable sex life (such as long term partners or married couples). High calorie or fatty meals may affect low long the medication takes to work.
Tadalafil: The active ingredient in Cialis. Oral tablets take up to 2 hours to achieve maximum benefit but can last up to 36 hours. Recommended for people who have a more spontaneous sex life. Not affected by the size of meals.
28
Which Active ingredient best suits your needs?
Sildenafil: The active ingredient in Viagra. Maximum effect and can last up to 4-6 hours. Recommended for those with a more predictable sex life (such as long term partners or married couples). High calorie or fatty meals may affect low long the medication takes to work.
Tadalafil: The active ingredient in Cialis. Maximum benefit but can last up to 36 hours. Recommended for people who have a more spontaneous sex life. Not affected by the size of meals.
Combination Sildenafil/Tadalafil: A powerful combination that gives you the increased blood flow of Sildenafil with the long acting qualities of Tadalafil. Best of both worlds.
29
What strength do you require?* This field is required.
Sildenafil 25 mg
Sildenafil 50 mg
Sildenafil 100 mg
30
What Strength do you Require?* This field is required.
Tadalafil 5 mg (Daily dose)
Tadalafil 10 mg
Tadalafil 20 mg
31
What Strength do you require?* This field is required.
Tadalafil 12 mg
Tadalafil 22mg
32
Which Strength do you require?* This field is required.
Sildenafil 30 mg
Sildenafil 50 mg
33
Which Strength do you require?* This field is required.
Sildenafil 40mg/Tadalafil 10mg
Sildenafil 22mg/Tadalafil 8 mg
34
Which Quantity do you require?* This field is required.
10 Strips ($80)
20 strips ($150)
35
What quantity would like to to have dispensed?* This field is required.
5 Tablets ($40)
10 Tablets ($75)
20 Tablets ($150)
36
What quantity would you like to receive?* This field is required.
5 Tablets ($50)
10 Tablets ($90)
20 Tablets ($185)
37
Confirm Total (CAD)
38
Would you prefer pick up or delivery?* This field is required.
Pick Up
Delivery
39
What is your preferred method of communication?* This field is required.
Phone
Email
Text Message
40
Thank you for your order!

You will receive a message by your preferred method of communication from our team when your medication is ready for pick-up or delivery. We will contact you for any futher medial questions if require further details.
41
Proceed to Checkout * This field is required.Your Total:
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Description
CAD
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42
Payment Methods
Debit Or Credit Card
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