Tadalafil Medical Assessment

Please answer accurately. Your responses will be reviewed by a licensed healthcare provider to determine whether tadalafil is appropriate for you.

Tadalafil — long-lasting ED treatment. Works in 30–60 minutes. Physician-prescribed, shipped discreetly.

Works in 30–60 min

Lasts up to 36 hours

Daily or as needed

Contact Information

Full Name *

Date of Birth *

Phone Number *

Email Address *

State *

1.What are you seeking treatment for?

Difficulty getting an erectionDifficulty maintaining an erectionBothOther sexual performance concerns

2.How long have you experienced these symptoms?

Less than 3 months3–12 monthsMore than 1 year

3.Do you take nitrates or nitrate-containing medications?

Examples: nitroglycerin, isosorbide mononitrate, or isosorbide dinitrate.

YesNoUnsure

4.Have you been diagnosed with any of the following?

Select all that apply.

5.Are you currently taking prescription medications?

YesNo

6.Have you previously used ED medication?

Examples: tadalafil (Cialis\u00ae), sildenafil (Viagra\u00ae), or vardenafil (Levitra\u00ae).

YesNo

7.Have you ever had an erection lasting longer than 4 hours?

YesNo

8.Do you have medication allergies?

YesNo

9.Is there anything else your provider should know?

YesNo

Telemedicine Consent & Patient Authorization

Please review and agree before submitting.

I consent to receive healthcare services through telemedicine. I understand that telemedicine involves the use of electronic communications and technology to allow me to interact with a healthcare provider when we are not in the same physical location.I understand the benefits and limitations of telemedicine, including that a provider may determine that telemedicine is not appropriate for my condition and may recommend an in-person evaluation.I understand that submitting this questionnaire does not guarantee a prescription. A licensed healthcare provider will review my medical information and determine whether treatment, including tadalafil or another medication, is medically appropriate.I authorize MedLeanRx and its healthcare providers to use the information I provide for evaluation, treatment, prescribing, care coordination, and other permitted healthcare purposes.I understand that I may ask questions about my treatment and telemedicine care and may withdraw my consent to telemedicine at any time, subject to applicable law and without affecting care already provided.

Patient Attestation

I certify that the information I provided is truthful, accurate, and complete. I understand that withholding or providing inaccurate medical information could result in serious health risks.

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