MEN'S HEALTH PAYMENT FORM

MEN'S HEALTH PAYMENT FORM

Please complete this form to place your men’s health compounded medication order.These medications are not covered by insurance and are available as an out-of-pocket payment. Your card will be charged immediately upon submission (this is not a temporary hold).Please bookmark this page for future refills, as this same payment form will be used each time and we cannot store cards on file.By submitting this form, you acknowledge that all orders are final and non-refundable.Questions? Contact us at clinic@skippackpharmacy.com.
RECEIVING YOUR MEDICATION

Based on if you select if you would like it discreetly shipped or picked up in store, you will be notified from our team. If picking up in store, please come to Skippack Pharmacy to pick-up your prescription ONLY AFTER receiving an email or text that it is ready. You do not need to reach out to us --- we will be in touch with you the moment your medication is ready. Our pick-up hours are Mondays-Fridays 10 AM to 6 PM and Saturdays 10AM to 3PM. If you requested for it to be shipped, we will email you with tracking information once the RX is ready.
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email [Please be sure to add clinic@skippackpharmacy.com to your contact list as your "Order Ready" email will come from this email address & may end up in spam if not in your contact list]*
**non Comcast.net email preferred as Comcast email addresses have often gone to spam**
First time getting a men's health medication altogether.First time getting a men's health medication from Skippack Pharmacy.I am filling this out for an additional fill (same strength as last time)I am filling this out for an additional fill (different strength then last time)Other
Check-In: HOW DO YOU FEEL after taking the Men's Health medication?
Feel free to share any details you'd like us to know
What is the NAME OF THE PRESCRIBER who will/has sent/will be sending in the script for you? In case your script did not arrive & you would like us to help you get the script from the provider, PLEASE PROVIDE THE PROVIDER'S PHONE #. If Telehealth and unsure of provider's name, write telehealth company name.*
PICK UP IN PERSON (No additional cost)TRIMIX/QUADMIX SHIP IT TO ME ($30 shipping fee) ***PLEASE MAKE SURE YOU ALSO SELECT "SHIPPING FEE" IN ADDITION TO SELECTING THE MED*** If you don't put a checkmark next to the shipping fee below or see that you've been charged $30 for it at checkout, your order will be delayed.GENERAL NON-REFRIGERATED SHIP IT TO ME ($10 shipping fee) ***PLEASE MAKE SURE YOU ALSO SELECT "SHIPPING FEE" IN ADDITION TO SELECTING THE MED*** If you don't put a checkmark next to the shipping fee below or see that you've been charged $10 for it at checkout, your order will be delayed.
Mailing Address (if Picking Up, Home Address; if Shipping, put address UPS can deliver to) ***WE CANNOT SHIP TO A PO BOX****

Street Address

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Postal / Zip Code
Date Submitted

MonthDayYear
Date
Refill Reminder / Feedback Date NOTIFICATION

MonthDayYear
Date
1 Fill3 Fills5 Fills2 Fills4 Fills6 Fills7 Fills8 Fills9 Fills10 Fills
Orals, RDTs, injectables, or topicals?

We've made multiple options available but at the end of the day, the choice is yours.
ERECTILE DYSFUNCTION: The medications for erectile dysfunction have an escalating scale. Most patients start by taking either oral sildenafil (25mg, 50mg, and 100mg) or tadalafil (2.5mg, 5mg, 10mg, and 20mg). Sildenafil is taken as needed. Tadalafil can be taken daily (2.5mg and 5mg) or as needed (5mg, 10mg, and 20mg).

The rapid dissolve tablets (RDTs) would be recommended next. We carry RDT versions of sildenafil (110mg RDT and 150mg RDT) and tadalafil (20mg RDT and 75mg RDT). These versions have a faster onset of action and are higher doses compared to the previous oral medications. Speak with your doctor to see if these options are right for you.

If neither of these options are effective for you, do not worry, we have another option! Injectable formulations are available (PGE, Trimix, and Quadmix) and are recommended after inadequate results from sildenafil or tadalafil. These injections are more effective and may work faster compared to the oral formulations. There are many dosages to choose from and it is highly recommended to speak with your doctor throughout the process to determine what dose is right for you.

It is recommended to start low and slowly increase the dosing until effective results are obtained. This process may take some trial and error to find what is best for you, so continuously speak with your doctor before making any dosing changes.

PGE is made up of one medication and is available in two strengths. Trimix includes PGE/papaverine/phentolamine. Quadmix is a combination of PGE/papaverine/phentolamine/atropine. PGE is the main active ingredient that aids in ED. Papaverine, phentolamine, and atropine provide synergistic effects that make the injections more effective, while decreasing the side effects from higher PGE dosing requirements.

HAIR LOSS: Hair loss has 3 different formulations including finasteride tablets, minoxidil 5% topical formulations, and ManeTain (Minoxidil 5%/Fluocinolone Acetonide 0.01%/Retinoic Acid 0.01%/Vitamin E Acetate 0.5% solution). Speak with your provider about which formulation is best for you.

ANTI-AGING: Anti-Aging has two different formulations available in NADvantage (topical crean) and NAD+ injection (500mg powder, when reconstituted 50mg/mL). Speak with your provider to see which option is right for you.

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After selecting what you prefer in the next question, please make sure when you select a product, that the product formulation matches what you would like to receive.

To make it easier we have split the products up in categories based on the drug:
- Sexual Health
  - Sildenafil
  - Sildenafil RDT
  - Tadalafil
  - Tadalafil RDT
  - PGE
  - Trimix
  - Quadmix
- Hair Loss
  - Finasteride tablets
  - Minoxidil 5% topical
  - ManeTain (Minoxidil 5%/Fluocinolone Acetonide 0.01%/Retinoic Acid 0.01%/Vitamin E Acetate 0.5% solution) topical
- Anti-Aging
  - NADvantage topical
  - NAD+ injectable

Please select which medication you are paying for. Ensure it is the right formulation (orals, RDTs, vials, topicals). *

Sexual Health: Sildenafil

Sildenafil 25mg

$30.00

Sildenafil 50mg

$36.00

Sildenafil 100mg

$44.00

Sildenafil 110mg RDT

$80.00

Sildenafil 150mg RDT

$120.00

NON-REFRIGERATED SHIPPING FEE

Please select this option if you would like the medication shipped to you. By selecting this you, agree with our shipping disclaimer.

$10.00

Sexual Health: Tadalafil

Tadalafil 5mg

Taken daily or as needed

$75.00

Tadalafil 2.5mg

Taken daily

$60.00

Tadalafil 10mg

Taken as needed

$36.00

Tadalafil 20mg

Taken as needed

$44.00

Tadalafil 20mg RDT

Taken as needed

$80.00

Tadalafil 75mg RDT

Taken as needed

$120.00

NON-REFRIGERATED SHIPPING FEE

Please select this option if you would like the medication shipped to you. By selecting this you, agree with our shipping disclaimer.

$10.00

Sexual Health: PGE

PGE1: PGE 40 mcg/mL

$115.00 Vials

PGE2: PGE 80 mcg/mL

$115.00 Vials

Reversal Agent

Phenylephrine 1mg/mL (5mL)

$63.50 Vials

REFRIGERATED SHIPPING FEE

Please select this option if you would like the medication shipped to you. By selecting this you agree with our shipping disclaimer.

$30.00

Sexual Health: Trimix

T105: PGE 10mcg / papaverine 30mg / phentolamine 1mg/mL

$132.25 Vials

T106: PGE 25mcg / papaverine 20mg / phentolamine 1mg/mL

$132.25 Vials

NB-243: PGE 20mcg / papaverine 30mg / phentolamine 3mg/mL

$149.50 Vials

NB-343: PGE 30mcg / papaverine 30mg / phentolamine 3mg/mL

$149.50 Vials

SB5: PGE 50mcg / papaverine 30mg / phentolamine 3mg/mL

$149.50 Vials

SB6: PGE 60mcg / papaverine 30mg / phentolamine 3mg/mL

$149.50 Vials

ST2: PGE 100mcg / papaverine 30mg / phentolamine 3mg/mL

$155.50 Vials

RE1: PGE 200mcg / papaverine 30mg / phentolamine 3mg/mL

$245.25 Vials

Reversal Agent

Phenylephrine 1mg/mL (5mL)

$63.50 Vials

REFRIGERATED SHIPPING FEE

$30.00

Sexual Health: Quadmix

FA: PGE 20mcg / papaverine 20mg / phentolamine 2mg / atropine 200mcg/mL

$138.00 Vials

QM2: PGE 60mcg / papaverine 30mg / phentolamine 3mg / atropine 200mcg/mL

$179.50 Vials

QM3: PGE 150mcg / papaverine 30mg / phentolamine 3mg / atropine 200mcg/mL

$192.25 Vials

Reversal Agent

Phenylephrine 1mg/mL (5mL)

$63.50 Vials

REFRIGERATED SHIPPING FEE

$30.00

Hair Loss

Finasteride 1mg tablets

Taken once daily

$1.00 Quantity

Minoxidil 5% topical aerosol

Four month supply (four 60g cans)

$84.43 Quantity

Minoxidil 5% topical aersol

One month supply (one 60g can)

$47.13 Quantity

Minoxidil 5% topical solution

One month supply (one 60mL bottle)

$47.13 Quantity

ManeTain

(Minoxidil 5%/Fluocinolone Acetonide 0.01%/Retinoic Acid 0.01%/Vitamin E Acetate 0.5% solution) 100ml spray bottle

$138.00 Quantity

NON-REFRIGERATED SHIPPING FEE

Please select this option if you would like the medication shipped to you. By selecting this you, agree with our shipping disclaimer.

$10.00

Anti-Aging

NADvantage

Use as directed: (Nicotinamide Adenine Dinucleotide 10%) 30g Cream

$142.00 Quantity

NAD+ Injection 500mg vial

Use as directed: Includes Bacteriostatic Water and 10mL mixing syringe

$238.04 Quantity

NON-REFRIGERATED SHIPPING FEE

Please select this option if you would like the medication shipped to you. By selecting this you, agree with our shipping disclaimer.

$10.00

REFRIGERATED SHIPPING FEE

$30.00

Sexual Health: Bimix

BM3: Papaverine 30mg/ml |Phentolamine 3 mg/ml

$152.50 Vials

Enter coupon

Total

$0.00

Payment Methods

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ACH Bank Transfer

If you do not see a thank you confirmation on the next page or get an error (Error 1 -- your card is declining, please try reprocessing with another card, Error 2 - our system issue, please email: clinic@skippackpharmacy.com or text 267-766-0076 to inform us so we can fix it on our end), your submission did not go through and payment is not confirmed. Please keep an eye out in your provided email and check your spam email as well from clinic@skippackpharmacy.com. Skippack Pharmacy will NOT provide a refund after the prescription is ordered for any reason. If you agree, please click on the box on the left, sign below and then press the submit button. ONCE THE PRODUCT LEAVES OUR PHARMACY (PICKED UP OR SHIPPED TO YOU), THERE ARE NO REFUNDS.
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MEN'S HEALTH PAYMENT FORM

RECEIVING YOUR MEDICATION

Orals, RDTs, injectables, or topicals?

Payment Methods