Sexual Health Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.ED Treatment OptionsSelect Your Desired Product *Sildenafil (Generic Viagra) ✔Medically Equivalent to Viagra✔Results in 30-60 Minutes✔Effects can last for up to 4 hours✔From $1.40 a pillClick Here For More InformationTadalafil (Generic Cialis)✔Medically Equivalent to Cialis✔Can be taken before you plan to havesex, or daily for spontaneous sex✔Effects can last for up to 36 hours✔From $1.19 a pillClick Here For More InformationTadalafil Gummies ✔Active Ingredient in Cialis✔Can be taken before you plan to havesex, or daily for spontaneous sex✔Effects can last for up to 36 hours✔From $2.30 a gummyClick Here For More InformationSelect Desired StrengthSildenafil Tablets? Select desired strength *25 MG - $ 10.0050 MG - $ 25.00100 MG - $ 50.00Tadalafil Tablets? Select desired strength *5 MG - $ 10.0010 MG - $ 25.00200 MG - $ 50.00Tadalafil Sex Gummies? Select desired strength *6 MG - $ 10.0012 MG - $ 25.0018 MG - $ 50.00PLEASE ANSWER A FEW QUESTIONS BELOW SO OUR MEDICAL TEAM CAN REVIEW YOUR TREATMENT.Patient Name: *FirstMiddleLastSex *MaleFemaleDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOnline Treatment Agreement *I understand that an online medical visit can be a great option for minor medical issues and not ideal for severe or life-threatening illnesses. I understand that treatment offered by prescribers of MyOnlineConsultation.com is on the basis of clinical judgment, in the absence of a complete physical examination. I agree to follow up with a doctor for in-person evaluation or seek emergency care if my symptoms worsen or do not improve in a timely manner.Patient consent to download medical history? *YesNoDo you have any condition that may render you incapable of making sound medical decisions? *Yes, I have a condition that may render you incapable of making sound medical decisionsNo, I do not have any such conditionDo you have an allergy to a particular medication? *Yes, I have a history of drug allergiesNo known drug allergiesList all the medicines you are allergic to: *Medication Disclosure Clause *I hereby certify that I am NOT currently taking any medication including OTC or supplements and agree to indemnify and hold harmless the reviewing prescriber and/or employees of the prescriber harmless from any loss, damages, liability, legal liability and expenses resulting from withholding or non-disclosure of my medication of any other vital medical information.Do you have any of these conditions? *Deformation of the penisHeart diseaseBlood disorder (leukemia or myeloma)DiabetesLiver or kidney diseasesLow testosterone levelSickle cellNone of these diseasesDo you have hypertension? *My blood pressure is normal (lower than 130/90)I have elevated blood pressure (greater than 160/100)Do you take any of these medications? *Nitrates. nitroglycerin. isosorbide dinitrate or mononitrateTerazosin. Doxazosin or TamsulosinAlfuzosin or SilodosinFluconazoleNone of these medicationsDo you currently take any medications, including over-the-counter drugs? *YesNoList all the medications you take, including over-the-counter drugs. *ED Evaluation - Briefly describe your ED symptoms and reason for this consultation. *Which of these medical conditions apply to you? *Low libido (lack of interest in sex)Premature ejaculationErectile dysfunctionI drink alcohol excessivelyI have problems within my relationshipI suffer from depression, anxiety, bipolar, psychosis or other psychiatric disordersWhen did your symptoms start? *Less than SIX months6-12 months agoOver a year agoSymptoms started at a young age (before the age of 21)Are you currently taking or have you previously taken medication for ED? *YesNoWhat medications have you taken or are currently taking for ED. *Have you previously visited the doctor for ED? *YesNoBriefly explain your last visit to the doctor for ED. *When was your last in-person doctor visit? *In the last 3 monthsIn the last 3 to 6 monthsIn the last 6 to 12 monthsOver 12 months agoHave NEVER seen a doctor in-personTreatment Warning and Precaution *I understand that I must not take Viagra or Cialis with Nitrates, terazosin, doxazosin, tamsulosin, alfuzosin, and silodosin or fluconazole to avoid severe adverse reactionPayment Confirmation *I authorize the prescriber to collect any consultation fees due for this service from RxCompoundStore.com.Prescription will be sent to RxCompoundStore.com, 8950 SW 74th Court, Suite 101, Miami, FL 33156. Ph: 786-803-8947. *Yes, I agreePLEASE UPLOAD THE FRONT OF YOUR ID * Click or drag a file to this area to upload. PLEASE UPLOAD THE BACK OF YOUR ID * Click or drag a file to this area to upload. Leave a comment or feedback (Optional)Please Sign Your Name *Clear SignatureTotal To Be Charged$ 0.00Payment *PayPal CheckoutCredit CardCard NumberExpiration DateSecurity CodeCard Holder NameFinish and Pay