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.

First Name*
Last Name*
Phone Number *
Email *
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?

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?*

Enter your blood pressure reading taken within the last 6 months. For Example Systolic 120/Diastolic 80.*

How did you hear about this product?

Date : 01/20/2022

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