Sildenafil Order Form
Sildenafil
Sildenafil 20mg ($1.60 per tab)
Sildenafil 25mg ($4.00 per tab)
Sildenafil 50mg ($8.00 per tab)
Sildenafil 100mg ($10.00 per tab)
Patient Name
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Patient Phone
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Patient Date of Birth
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Day
Year
Date
Patient Email
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example@example.com
Patient Address
Street Address
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Primary Care Physician
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Physician Phone
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