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Medical Intake Form

You have purchased a prescription product. To complete your order complete the form below and we will forward your information to one of our participating providers who can treat you from the comfort of your home.

Order #*

Please enter the order number found on the Order Confirmation email that you received. Your information will only be viewed by our Medical Team and is stored on HIPAA compliant servers.

First Name*
Last Name*
Phone Number *
Email *
Address*
City *
State Of Residence*
Zip Code*
Are you allergic to any medication? *
What medications or vitamins are you taking? *
What is your date of birth? *
Gender* Female Male
Would you like to increase your level of sexual interest and satisfaction? *


Why do you want to improve your sexual experience? *





Are you currently in a relationship?



Are you currently pregnant or intending to become pregnant? *


I understand that I cannot take this medication if am pregnant or intending to become pregnant as it may cause premature labor.

Do you have children?*



Have you gone through menopause?*


Have you ever been diagnosed with vaginal atrophy?*


Do you have issues with vaginal dryness?*


Do you have pain during sex?*


Have you discussed this with your gynecologist?*


Have you ever been diagnosed with the following:*



When did you have your most recent pap smear?*
Was it normal?*


Are you currently taking any medications for hypertension or the following medications?*







Do you have any liver problems?*
Including, but not limited to, viral hepatitis, autoimmune hepatitis, cirrhosis, genetic liver disorders, liver or bile duct cancer, chronic alcohol abuse, or nonalcoholic fatty liver disease.



Do you smoke?*


How did you hear about this product?







We must have a clear photo of your face and your photo ID so that we may properly identify and treat you. Your information is kept strictly private. We are a HIPAA compliant website. Take a pic right from your phone or upload a photo from your computer.
Faceshot
Photo ID
Only the medical team will see your photos

Note: Your medical information will not be saved until you click on the SUBMIT button.