consultall

Online Consultation

General Information
The following questions provide us the information necessary to process your request and to maintain appropriate information about you. Please fill in the fields and respond to all of the questions.
First name
Last name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Day Phone
Evening Phone
E-mail

Personal Identification Code
[your code should consist of your First
and Last initials followed by the last
4 digits of your social security number]

By submitting this consultation form:
I understand the potentail side effects and have read the consumer information for Pfizer regarding VIAGRA™.	Yes No
I understand that I will be billed $75 for this consultation, only if it is approved. I also understand that I will be billed for the medications below if my consultation is approved.	Yes No
I certify that all information I provide is truthful and complete.	Yes No
How did you find our service?

Amount to order

For most patients, the recommended dose is 50 mg taken, as needed, approximately 1 hour before sexual activity. However, VIAGRA may be taken anywhere from 4 hours to 0.5 hour before sexual activity. Based on effectiveness and toleration, the dose may be increased to a maximum recommended dose of 100 mg or decreased to 25 mg. The maximum recommended dosing frequency is once per day.
-Pfizer Product Information

If I am approved, I would like my first prescription to be for the following amount:

Highlight item below:

Cimetidine (generic for Tagamet™) (800 mg), a nonspecific CYP inhibitor, caused a 56% increase in plasma sildenafil concentrations when coadministered with VIAGRA (50 mg) to healthy volunteers.
-Pfizer Product Information

This would indicate that increased effectiveness would be noted with the same dose of Viagra™ taken with 800mg of Cimetidine (generic for Tagamet™). Anecdotal reports (non- scientific) have supported this.
We are pleased to be able to make Cimetidine (generic for Tagamet™) 200mg (non-prescription strength) available at low cost for our patients.

No additional shipping charges will be applied.

Highlight item below:

Shipping Information
Send my prescription to me as I have indicated below:
Within the US, orders are shipped Express Mail at a charge of $15.00 dollars.
Do you wish do waive signature on delivery? [US ONLY]	Yes No
Please make sure that your local customs allow the import of VIAGRA™. If it is returned unopened by customs, we will refund the cost of medication less a 20% restocking fee.
International express mail is used for orders outside the US. Shipping is charged at $20.00 to $30.00 dollars depending on country

Method of payment
Please enter your Credit Card Information
If you are uncomfortable with using your credit card online, please type 'Phone Contact' in the credit card number area and one of us will contact you.
I certify that I am authorized to use the credit card I have selected below.	True False
Select Credit Card
Name as it appears on card:
Credit Card Number:
Expiration Date:

Medical history
What is your month and year of birth?	(mm/yy)
What is your height?	feet inches
What is your current weight?
Your Gender?
If you have any known allergies, please list them here:
Please list all over-the-counter and prescription drugs you are currently taking and length of time you have been taking them. For example: Prozac 20 mg. twice daily for 6 months, etc...
Please list past surgical history. Include description of surgery and date of surgery. For example: Prostatectomy - 4/96, etc...

Do you have or have you had any of the following medical problems?
Prostate Cancer	Hypertension	Diabetes Mellitus
Obesity	Enlarged Prostate	Heart Disease
Thyroid Disease	Liver Disease	Low Testosterone
Kidney Disease	Stroke	Depression
Anxiety	Spinal Cord Injury	Schizophrenia

Have you ever been diagnosed with Attention Defecit Disorder?	Yes No
Are you currently being treated for Attention Defecit Disorder?	Yes No
Have you had a general physical examination and been found in good health with the exception of those medical problems noted elsewhere in this consultation?	Yes No
Do you suffer from high blood pressure?	Yes No
Do you consume more than 2 servings a day of alcohol?	Yes No
Do you smoke cigars or cigarettes?	Yes No
Have you a history of substance abuse?	Yes No
Are you taking, or have you ever taken any medication for the acute treatment of chest pain?	Yes No
Do you have chest pain if climbing two flights of stairs?	Yes No
Do you currently use any pharmaceuticals not prescribed by a health care provider?	Yes No
Are you depressed often?	Yes No
Have you ever taken any of the following medications for chest pain?	Yes No

Drug	Manufacturer	Drug	Manufacturer
NITROGLYCERIN		ISOSORBIDE MONONITRATE
Deponit	Schwarz Pharma, Inc.	Imdur	Key Pharmaceuticals
(transdermal)		Ismo	Wyeth-Ayerst Laboratories
Minitran	3M Pharmaceuticals	Monoket Tablets	Schwarz Pharma, Inc.
Nitrek	Bertek Pharmaceuticals, Inc.	ISOSORBIDE DINITRATE
Nitro-Bid	Hoechst Marion Roussel	Dilatrate SR	Schwarz Pharma, Inc.
Nitrodisc	G.D. Searle Company	Isordil	Wyeth-Ayerst Laboratories
Nitro-Dur	Key Pharmaceuticals	Sorbitrate	Zeneca Pharmaceuticals
Nitrogard	Forest Pharmaceuticals, Inc.	ERYTHATYL TETRANITRATE
Nitroglyn	Kenwood Laboratories	PENTAERYTHRITOL TETRANITRATE
Nitrolingual Spray	Rhone-Poulenc Rorer Pharmaceuticals, Inc.	SODIUM NITROPRUSSIDE
NitrolOintment (Appli-Kit)	Savage Laboratories
NItrong	Rhone-Poulenc Rorer Pharmaceuticals, Inc.
Nitro-Par	Parmed Pharmaceuticals
Nitrostat	Parke-Davis
Nitro-Time	Time-Cap Laboratories
Transderm-Nitro	Novartis Pharmaceuticals Corporation

Sexual history
Please answer these questions about your current concerns. This information enables us to evaluate whether the use of Viagra™ is appropriate. Please be assured that all information is completely confidential, and is protected by professional privilege. Please answer all questions as completely and descriptively as possible.
What is currently bothering you about your sexual health?
For how long has this been a problem?
Do you have problems achieving erection?	Yes No
Do you lose your erection before or after penetration?	Before After
Have you ever been evaluated for erectile dysfunction?	Yes No
Have you ever seen a physician to be treated for male sexual dysfunction? Please list type of treatment (i.e., injection therapy, penile implant, oral medication) and date of treatment.