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* Note Fill Out the Form Below & A State Licensed Physician will Review it Within 8 Hours. If The Physician Has Any Further Questions They Will Contact You By E-Mail.



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*If you do not see your state on this list, please let us know at info@edmedcare.com and we will add that license in your state as soon as we can (we are constantly striving to add each state as everyone is important to our EDmedcare family)

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Treatment You are Requesting From the prescriber:

Check Out our Men's Health Page for Information on Blood Pressure and Age.
Blood Pressure Top number (Systolic):
Blood Pressure Bottom Number (Diastolic):

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Tobacco Usage:

Alcohol Usage:


Recreational Drug Usage:

Which drugs?:
How did your ED start?:


Have you been maintaining an erection satisfactorily within the past year?


Which of the following treatments have you used or taken in the past to treat Erectile dysfunction?

If you have taken ED treatments in the past, did you experience any side effects or complications from any of the ED therapies?

What side effects did you experience?:
Do you have any types of allergies?:

Describe your allergies:
Meds, herbs, vitamins taken / 2 weeks:
Do you have any of these conditions?:

Cardiovascular Risks:

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* * If the Doctor has Any Further Questions They Will Email You.

I acknowledge that I am the Patient and answered the questions truthfully and to the best of my knowledge. In addition, EDmedcare will not share any Patient Health Information with any third party unless required to do so by law. By clicking on the submit button, it is understood that the Patient agrees to these terms. You may see our whole privacy policy at the bottom of the page.

we can help you

There are some things in life that you cannot control. Thanks to technology, medical research, erectile dysfunction will not be one of them.

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