medical intake form

  • Get the Help You Need — Fast, Simple, and Affordable

    Call or text Dr. Kaplan anytime if you have questions about which medication is right for you. The flat $79 fee covers everything — no surprise bills. You'll get a coupon and a local pharmacy will fill your prescription (Viagra or Cialis generics) for as little as 30–40¢ per tablet — often ready in under an hour. Treatment is not provided until your intake form is completed and reviewed.
  • Date Of Birth
     - -
  • Format: (000) 000-0000.
  • Which medication would you like?*
  • Have you ever taken ED medication previously?*
  • Have you ever experienced a side effect from ED medication?*
  • Have you ever taken nitroglycerin or heart medications with nitrates?*
  • Have you had a heart attack, stroke, chest pain, or been told you have aortic stenosis?*
  • Do you have poorly controlled or uncontrolled high blood pressure?*
  • Do you have a bleeding disorder, leukemia, or multiple myeloma?*
  • Do you have severe liver or kidney disease?*
  • Do you have retinitis pigmentosa or NAION (eye disease)?*
  • Do you have a history of priapism or Peyronie’s disease?*

  • Please review our Terms & Conditions and Arbitration Agreement before proceeding.

  • I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations, and I agree to receive telehealth services.

  • By submitting this form, you authorize us to use your health information for treatment, payment, and healthcare operations. You also consent to telehealth services.

    View our Privacy Policy / Notice of Privacy Practices:
    Privacy Policy

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    ED VISIT

    Medical Services

    $79.00
      
    Total
    $0.00
    Credit Card Details
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