EnRoute Health

ED Preliminary Questionnaire (Sildenafil / Tadalafil)

Please correct the errors described below.

Only men between the ages of 18 and 65 will be considered for Sildenafil or Tadalafil through the use of telemedicine (Video Visit). Due to potential health risk associated with Sildenafil and Tadalafil, adults older than 65 should only be screened by their primary medical provider. Available to Texas residents only! Pay only if you qualify. PayPal Invoice for $19 (+processing fee) will be emailed to you if you qualify. Once payment is collected, a clinician will contact you to verify your information and pharmacy information. Your presciption will be sent to the pharmacy of your choice.

Patient Information

Exp 1231231234

Pharmacy Information

Exp: Walgreens, Walmart, CVS, HEB
Exp: 1231231234

Have you ever been told you have or have had any of the following medical conditions?

Are you currently taking any of the following medications?

Please list CURRENT medications (include over the counter).

Do you currently have or have had any of the following symptoms with or without exercise?

List Any Known Drug Allergies

Medication request

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