MinuteMD Male Sexual Enhancement Questionnaire

1

What is your full name as it appears on your government issued ID?* This field is required.

First Name

Last Name

2

Are you at least 18 years of age with United States government issued ID?* This field is required.

YESNO

3

What is your email address?* This field is required.

example@example.com

4

What is your shipping address?* This field is required.This is where we will instruct the pharmacy to mail your medication.

Street Address

Street Address Line 2

City

State

Zip Code

Country

5

Are you able to get and keep an erection?* This field is required.

YESNO

6

Are your erections hard enough to penetrate (enter) your partner?* This field is required.

YESNO

7

Are you able to maintain your erection after penetrating (entering) your partner?* This field is required.

YESNO

8

Are you able to maintain your erection to completion of intercourse?* This field is required.

YESNO

9

Is your degree of sexual activity satisfying for you and your partner?* This field is required.

YESNO

10

Please list all medications (including frequency and dosage) and any supplements that you are currently taking:* This field is required.If you are not taking anything, please confirm this by typing NONE.

11

Please provide a picture of your photo identification (drivers license/passport):If you do not have this now, you can skip this step. However, it will be required prior to being prescribed any medication.

12

Signature* This field is required.By signing this form, you certify that you have answered the questions above honestly to the best of your ability.

Clear