MEN'S HEALTH PAYMENT FORM

MEN'S HEALTH PAYMENT FORM

Please complete this form to order your men's health medication order. Compounded medications are not covered by insurance and will be available out of pocket. Patients are responsible for the cost of the medication up front. This is NOT a hold on your credit card, by inputting your credit card number below, you will be charged immediately. Please contact us at clinic@skippackpharmacy.com prior to submitting if you have any questions! Once the order is placed through this form, you acknowledge there are no refunds. ***BOOKMARK THIS PAGE: We cannot put your card on file so you will have to fill out a new payment form when you need a refill --> you will use this same payment link for your initial medication & for refills for following months***
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 7 PM and Saturdays 10AM to 2PM. 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**
Is this your first time ordering injectables/oral formulation or are you getting a refill or additional fill?*

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)I am ordering an injectable formulation for the first time.I am ordering an additional fill of an injectable formulation.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.*
How do you want to receive the medication when ready?*

PICK UP IN PERSON (No additional cost)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.
Mailing Address (if Picking Up, Home Address; if Shipping, put address UPS can deliver to) ***WE CANNOT SHIP TO A PO BOX****

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Submitted

MonthDayYear
Date
Refill Reminder / Feedback Date NOTIFICATION

MonthDayYear
Date
How Many Fills Are You Paying For?*

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. You will need to click the acknowledgement (the next square box) after reading below.
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 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 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.

**If you've been getting great results, is there a point to switch? That is your choice but if you switch and do not get similar results or have issues, we will not be able to swap out vials**

If unsure which to choose, please speak to your provider. We leave it 100% up to you :)

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
ED: Oral, RDTs, and Injectable Dosing Availabilities

Click the chart below to zoom in

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

Sexual Health: Sildenafil

Sildenafil 25mgTaken as needed

$30.00

Sildenafil 50mgTaken as needed

$36.00

Sildenafil 100mgTaken as needed

$44.00

Sildenafil 110mg RDTTaken as needed

$80.00

Sildenafil 150mg RDTTaken as needed

$120.00

SHIPPING FEEPlease select this option if you would like the medication shipped to you. Cold packages are shipped Monday-Friday via UPS Next Day Saver. By selecting this you, agree with our shipping disclaimer.

$30.00

Sexual Health: Tadalafil

Tadalafil 5mgTaken daily or as needed

$75.00

Tadalafil 2.5mgTaken daily

$60.00

Tadalafil 10mgTaken as needed

$36.00

Tadalafil 20mgTaken as needed

$44.00

Tadalafil 20mg RDTTaken as needed

$80.00

Tadalafil 75mg RDTTaken as needed

$120.00

$30.00

Sexual Health: PGE

PGE1: PGE 40 mcg/mL

$115.00 Vials

PGE2: PGE 80 mcg/mL

$115.00 Vials

Reversal AgentPhenylephrine 1mg/mL (5mL)

$63.50 Vials

$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 AgentPhenylephrine 1mg/mL (5mL)

$63.50 Vials

$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 AgentPhenylephrine 1mg/mL (5mL)

$63.50 Vials

$30.00

Hair Loss

Finasteride 1mg tabletsTaken once daily

$1.00 Quantity

Minoxidil 5% topical aerosolFour month supply (four 60g cans)

$84.43 Quantity

Minoxidil 5% topical aersolOne month supply (one 60g can)

$47.13 Quantity

Minoxidil 5% topical solutionOne 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

$30.00

Anti-Aging

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

$142.00 Quantity

NAD+ Injection 500mg vialUse as directed: Includes Bacteriostatic Water and 10mL mixing syringe

$238.04 Quantity

$30.00

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

ACH Bank Transfer

**You might wonder why this reminder is here---its because many of our patients who want shipping forget to select it & thus delay their order. We value your time and thus put this additional reminder to prevent delays...IF you would like the package shipped to you, please make sure the total above reflects having $30 added to the cost of the item(s) ordered.**
PLEASE CLICK THE EMPTY SQUARE BOX BELOW & THEN SIGN TO ACKNOWLEDGE*

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.
Signature*

Clear
Date

MonthDayYear
Date
Refill Notification Date

MonthDayYear
Date
Should be Empty:

MEN'S HEALTH PAYMENT FORM

RECEIVING YOUR MEDICATION

Orals, RDTs, injectables, or topicals?

ED: Oral, RDTs, and Injectable Dosing Availabilities

Payment Methods