Confidential Patient Contact Form

E.D. Patient Contact Form

Fill in our form below and we will contact you back on the next business day to confirm your information and discuss the details necessary to call your physician and request a prescription for Sildenafil on your behalf.

  • Personal Information

  • Current Prescription Information

  • Either a Brand Rx or a Generic Rx would be a "yes".
  • Current Physician Information

    Please provide us with your current physician so that we can contact them to get you a prescription.
  • Submission Section

  • If you would like to send us a message, type it here.