Viagra Consultation Form

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 . You can also visit www.viagra.com

If you are seeking Viagra treatment, we suggest that you visit the following links before filling out our consultation form.

Warning: List of Contraindicated Drugs, Causes of Impotence

Note: If you are taking any of these nitrate medications on the List of Contraindicated Drugs, please do not waste your time filling out a consultation form because our physicians will not prescribe you the drug.  Used together with Viagra, these nitrate medications will cause dangerous drug interactions. Your safety is one of our major concerns.

 

Online Consultation Form

Certification & Warranty Of Applicant
Consent to
Medical Care
Extremely Important! I have read both the Certification and Warranty of Applicant and the Consent to Medical Care and agree to both of them.
NO YES Do you want to request a consultation and establish a patient/physician relationship with Net Doctor International's physicians? [ if answered NO,we can not process]
Consent to Access Medical Records
Extremely Important!

I have read and grant Net Doctor International physicians to access my medical records if they need to review them in order to assure that they can provide me with quality health care. [ must be checked if you agree for us to continue your treatment ]

YES NO _____Again do you grant the physicians of Net Doctor International Ltd. to access your medical records?[must be answered so that we can continue your treatment]
no yes Are you taking any nitrate medications?
Billing Information
Payment Type:
Credit Card
Money Order (Leave Credit Cards fields blank)
Credit Card Type: (required for Credit Card)
Credit Card Number:   (required for Credit Card) NO DASHES!
Credit Card CVV:   (required for Credit Card) What is CVV? Click Here
Expiration Date:   (required for Credit Card)
Shipping Method

Shipping Service:

  (required)
Personal Information
Email: (required for confirmation)
Name (First and Last): (required)
Shipping Address: (required) UPS WILL NOT DELIVER TO P.O. BOXES
City: (required)
State: (required)
Province/Region:   (International Only)
Zip/Postal Code:   (required)
Country:  
USA Phone: (8887778877, no dashes and spaces) required
International Phone:  (International Only)
Billing Address               Check if Billing Address is the same as Shipping
Address:   (required)
City:   (required)
State: (required)
Province/Region:   (International Only)
Zip/Postal Code:   (required)
Country: (required)
More Personal Information
Age:
(required)
Height:
   (required)
Weight (lbs):
(required)
Date Of Birth:
(MM/DD/YY)
(required)
Sex:
Male     Female (required)
Viagra Dosage

Choose Quantity:

(required) (Patients living in Japan will only be prescribe a maximum of 30 tablets)
Pill Cutter:
Do you want a $10 pill cutter to be included in your prescription? [ Recommended ]
Have you been diagnosed with:
no yes atherosclerosis (required)
no yes low testosterone (required)
no yes diabetes (required)
no yes prostate cancer (required)
no yes hypertension (required)
no yes cirrhosis of the liver (required)
no yes anxiety (required)
no yes heart attack (required)
no yes endocrine disorders (required)
no yes stroke (required)
no yes kidney disease (required)
no yes  spinal cord injury (required)
no yes thyroid disease (required)
no yes enlarged prostate (required)
Medical History

Are you on dialysis?      yes  no

Have you had an organ transplant?   yes  no  

Do you have a pacemaker? yes no

Please list ALL medications you are now taking:

Please respond to these questions regarding specific contraindicated medications:
Please make sure to answer these questions correctly. If you answer YES to any of the following six questions then you are not suitable for Viagra treatment. Be sure to answer these questions correctly to avoid delays of your consultation.

no yes Are you taking nitroglycerine? [ If yes, not suitable for  Viagra ]
no yes Are you taking erythromycin? [ If yes, not suitable for  Viagra ]
no yes Are you taking ketoconazole? [ If yes, not suitable for  Viagra ]
no yes Are you taking cimetidine? [ If yes, not suitable for  Viagra ]
no yes Are you taking itraconazole? [ If yes, not suitable for  Viagra ]
no yes Are you taking mibefradil?  [ If yes, not suitable for  Viagra ]
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 relevant?  no   yes (please specify)

Do you have any questions?

If you are a woman, describe why you are interested in taking Viagra: (you must have a qualifying medical reason, Viagra is not a recreational drug). Women may obviously leave blank all impotence-related questions which follow, please answer all other questions.

How would you describe your sex life?

Have you been treated for impotence previously?  no  yes  (please specify type of treatment and results)

Impotence occured:  Suddenly   Gradually

Impotence involves:  inability to maintain an erection  inability to get an erection

Which best describes your impotence:
  penis not at all firm
  penis not self-supporting but slightly firm
  hardness sufficient for sex but firmness is decreased

Are there ever times when you are not impotent?   no  yes (please specify)

Can you walk up two flight of stairs in 2 minutes? no yes

Can you walk two miles in 30 minutes? no yes

What is your blood pressure?

What is your cholesterol concentration?

Do you suffer from depression?  no