Viagra,Celebrex,Propecia,Proscar,Xenical,Consultation,Consultations,Prescription,Prescriptions

Please take the necessary time to carefully and truthfully complete all applicable questions on the form. Incomplete forms will not be submitted to our physicians for a consultation, as failure to provide the medical information required to render a professional opinion is prima facie grounds to deny a prescription. If you want to ask us any questions before submitting your form, see our Frequently Asked Questions or contact us .

Viagra	Personal Information
Name (First and Last)	required
Address	NO P.O. BOX PLEASE
City	required
State	required
Zip Code	required
Country
Phone	(8887771234, no spaces ) required
E-mail Address	required

Viagra	Current Information
Age	required
Height	required
Weight	required
Date Of Birth (MM/DD/YY)	required
Sex	Male Female

Viagra	Credit Card Information
Credit Card	required
Name Of Credit Card Holder	required ; NO DASHES!
Credit Card Number	required
Credit Card CVV	required What is CVV? Click Here
Expiration	required
Billing Address	required
City, State, Zip	required

Viagra	Quantity of Propecia/Proscar
Pill Cutter	Please send a pill cutter. I understand that my credit card will be billed US $ 10 which includes worldwide postage.
Quantity (if approved)
Shipping Method
Charge Approval	If I am approved for Propecia/Proscar, please bill my prescription on my credit card and send me my tablets immediately.

Have you	been diagnosed with?
yes no atherosclerosis	yes no heart attack
yes no low testosterone	yes no endocrine disorders
yes no diabetes	yes no stroke
yes no prostate cancer	yes no kidney disease
yes no hypertension	yes no spinal cord injury
yes no cirrhosis of the liver	yes no thyroid disease
yes no anxiety	yes no enlarged prostate

Medical History

Please list all medications you are now taking:

Please list all known allergies:

Are you being treated for other medical conditions at this time? no yes (please specify)

What is your past surgical history?

Do any diseases/disorders run in your family? no yes (please specify)

How much do you drink: none not much moderately heavily

Do you smoke? no yes packs per day

Do you consider anything else in your medical history to be relevent? no yes (please specify)

Do you have any questions?

Do you have the following conditions?	Viagra
Are you suffering from hair loss? If yes, for how long (since what age) have you been losing your hair?	yes no age
Was the onset of your hair loss sudden or gradual?	sudden gradual
Is male pattern baldness common in your family?	yes no
Do you understand that Proscar/Propecia is not to be taken by women, and that crushed/broken Propecia/Proscar tablets MUST not be handled by women who might be pregnant?	yes no
Do you understand the side effects of finasteride?	yes no

By submitting this form, I certify	that:
I have read and agree to the Net Doctor Group's waiver of liability.	True False
I am permitted to receive the medication I requested in the state/region/country indicated as the shipping address:	True False
I have provided truthful information to the best of my knowledge to Net Doctor Group's.	True False

Submit

Note to US patients: In many cases, a Net Doctor physician shall prefer to speak on the telephone briefly with patients prior to reaching a final decision. Please provide a telephone number (if different than above) where you may be reached and a convenient time in the 24 hours following the submission of your form. If you are not available at the time that the physician phones you, no message will be left, and if someone other than the patient answers the phone no details about the nature of the call or the caller will be disclosed. The physician will try to phone you on the following day at the same time, and if you still cannot be reached, we will contact you via e-mail.

Phone number ( if different from the above ) :

Convenient time to call:

Where did you find us? If you don't mind please be accurate. In the future if in case you forget our website when you have any questions just type "netdr" on any search engines. Thank you.

By submitting this form you are agreeing to pay a $50 consultation fee. If you are not approved for a prescription, you will not be charged.

Credit card FRAUD is a criminal offense in any country. Violators will be prosecuted to the extent of the law. We have successfully prosecuted three offenders so far and now they are serving time in jail. DON'T DO IT!