Tadalafil Order Form
Tadalafil (generic Cialis®)
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Tadalafil 5mg ($2.00 per tab)
Tadalafil 10mg ($8.00 per tab)
Tadalafil 20mg ($10.00 per tab)
Patient Name
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Patient Date of Birth
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-
Month
-
Day
Year
Date
Patient Phone Number
*
Please enter a valid phone number.
Patient Email
*
example@example.com
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Physician
*
Physician Phone #
*
Please enter a valid phone number.
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