What is your date of birth?

Have you taken erectile dysfunction medicine before?

Do you ever have difficulties getting or maintaining an erection that is satisfying enough for sex BEFORE ejaculation?

How often do you have a problem with this?

Did your problem with your erection start suddenly?

How long have you experienced a problem getting or maintaining an erection that is enough?

What is your blood pressure reading taken within the last 6 months?

Are you worried about having sex?

How often do you ejaculate sooner than you or your partner want to?

Do you Ejaculate with very little stimulation?

Are you stressed, annoyed, or frustrated by ejaculation problems?

How often have you had symptoms of depression or anxiety?

Do you….?

Do you have any of these conditions?

Tell us if you have any physical issues with your penis that make intercourse difficult

Write NA, if there is no physical issue.

Tell Us if you ever had any heart problems , low blood pressure, stroke, or circulation problems where taking ED medicines can be life-threatening

Write NA, if you don’t have any problem.

Have you ever been diagnosed with any of the following? Select all that apply to you

Have you ever taken or been prescribed nitrates or nitroglycerin or alpha blockers (doxazosin, prazosin or terazosin)?

Are you allergic to any medicine?

Do you take other medication(s) or have any other medical conditions?

Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.

Do you have any of these conditions?

Anything else you would like us to know?

How would you like to pay?

Billing and delivery details

Personal Details

Confirm Request and Agree to Terms