Please provide the following information as completely and accurately as possible. All information must be provided to process your consultation.

Your personal information (strictly confidential):
Name:
Address:
City:
State/County:       Zip Code/Post:
Country:
Phone:
Email:
Choose one of the following options.
If I am approved for Viagra�, I would like my first prescription to be charged to my credit card and dispensed by ViagraSales. Each prescription can be dispensed with up to 3 refills for a maximum order of 4 prescriptions (120 pills). I Request the following pill prescription: Select Quantity Desired: 05 pills @ �30 ea, 100 mg. dose (�150.00) 10 pills @ �27 ea, 100 mg. dose (�270.00) 30 pills @ �25.00 ea, 100 mg. dose (�750.00) All amounts are in UK Pounds. You may order up to 3 additional refills at this time or at a later date. Select number of additional refills to be ordered and PAID for at this time: No Refills   1 Refill   2 Refills   3 Refills
Send my prescription as indicated:
Gaurantee Next UK Only	�08.00
Royal Mail (Recorded)	�06.00
Air Mail (Recarded)	�10.00 Please allow 3 days - 2 Weeks
Credit Card Information:
Name of Credit Card Holder:
Enter Credit Card Type:	Please Select Master Card Visa
Enter Credit Card Number:
Billing Address:
Billing Zip/Postal Code:
If the address and zip/Postal code you listed above are the same as the address and zip code that your credit card statement is sent to, then don't enter anything for billing address and zip code.
Expiration (MM/YY):
For expiration dates in the year 2000 and above enter 00 for 2000, 01 for 2001, etc.
By submitting this consultation form: I certify that I am 18 years of age or older. I am permitted by law to receive these products in my region/country/locale. I understand the side-effects of this drug. I do not have a current prescription for Viagra� from another physician. I certify that I am allowed by law to use the credit card I have selected above. I understand that my credit card will be billed for this consultation       and that if I choose to have Viagra � dispensed from Cymedic Health,       this too will be billed to my account if my consultation is approved. I certify that I will answer all the questions truthfully.

Medical History:

Your Medical History informs us of any possible medical contraindications you may have to taking Viagra^�. This information would be required before any physician could treat you for any illness or condition.

What is your height (in inches)?
What is your current weight (in lbs)?
What is your month and year of birth?	(MM/YY)
Sex?	male     female
Are you taking any of the following?
Nitroglycerin	Nitrek (transdermal)	Nitro-Bid�
Nitrodisc	Nitro-Dur�	Nitrogard™
Nitroglyn	Nitrlingual Spray�	Nitrol� Ointment (Apoll-Kit)�
Nitrong	Nitro-Par	Nitrostar�
Nitro-Time	Transderm-Nitro�	Isosorbide Mononitrate
Imdur�	Ismo�	Monoket�
Isosorbide Dinitrate	Dilarate�-SR	Isordil�
Sorbitrate�	Erythatyl Tetranitrate	Pentaerythritol Tetranitrate
Sodium Nitroprusside
Do you have any of the following medical problems?
Coronary Artery Disease	Congestive Heart Failure	Valvular Heart Disease
Anatomic Deformation of the Penis	Peyronie's Disease	Multiple Myeloma
Obesity	Hypertension	Diabetes Mellitus
Prostate Cancer	Enlarged Prostate	Low Testosterone
Thyroid Disease	Atherosclerosis	Liver Disease
Kidney Disease	Stroke	Depression
Anxiety	Schizophrenia	Spinal Cord Injury
Endocrine Disorders	Sickle Cell Anemia	Leukemia
Have you had a complete physical exam with blood tests within the last year?  yes   no Do you consume more than 2 servings a day of alcohol?  yes   no Do you smoke cigars or cigarettes?  yes   no

Sexual History:
Please indicate on this form your current medical problems. It is the same information you would be asked if you visited our clinic or any other physician that specializes in sexual dysfunction. This and all the other information you have entered is encrypted and safe during transmission over the Internet. Once received by our physicians, it will be protected under patient/doctor privilege laws.

In the following questions, the term "erectile dysfunction" means the inability to achieve or sustain an erection that is adequate for normal sexual activity.

What is currently bothering you about your health?

Are you unable to achieve and sustain an erection that   is adequate for penetration until orgasm? yes no   Have you ever been evaluated for erectile dysfunction? yes no   I feel that I am incapable of having normal satisfying   sex without prescription medication. true false

Where did you hear about us? Referral Friend Newspaper Search Engine Email Television Other If newspaper, which?

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