$119 -- 15 100mg tablets
of GSC-100 -- $7.93 per pill
$179 -- 30 100mg tablets
of GSC-100 -- $5.97 per pill -- Good
Value!
$330 -- 60 100mg tablets
of GSC-100 -- $5.50 per pill -- Great
Value!
$450 -- 90 100mg tablets
of GSC-100 -- $5.00 per pill -- Best
Value!
*
A $25 fee applies to all non-U.S. orders
to cover shipping fees
Promotional/Coupon Code:
Please enter
promotional codes here.
Patient Information
For quicker processing, enter your full name and please avoid
the use of initials.
*First Name:
*Last Name:
*Gender:
MALE
FEMALE
*Email:
Please confirm your email address
has been entered correctly! Example: "username@domainname.com"
This will be our primary means of contact with you.
Provide your shipping address (NO PO BOXES ALLOWED).
*Shipping Address1:
*Shipping Address2: (optional)
*Shipping City:
*Shipping State:
*Shipping Country:
*Shipping Zip:
Provide your billing address (NO PO BOXES ALLOWED).
*Billing Address1:
*Billing Address2: (optional)
*Billing City:
*Billing State:
*Billing Country:
*Billing Zip:
Vital Statistics
The physicians and staff respect the privacy of your medical
information. All
information given during this consultation is
protected, secure and held
in complete confidence.
*Date of Birth: (ex. mm/dd/yyyy)
*Height (in inches)
*Weight (in pounds)
*Known Drug Allergies
If you have no known drug allergies, check none.
None
Otherwise list in box below.
Surgical History
*Description of Surgery/Date of Surgery:
If you have not had surgery, check none.
None
Otherwise list surgeries.
*Are you being treated for any medical conditions at this time?
Yes
No
*If yes then please describe:
*Have you been examined by a healthcare provider within the last 12
months?
Yes
No
Patient
Medical History
*Do you have or have
you had any of the following medical problems?
*Heart Disease?
Yes
No
*Heart Problems?
Yes
No
*High Blood Pressure(hypertension)?
Yes
No
*Epilepsy or seizure disorder?
Yes
No
*Stroke?
Yes
No
*Any forms of cancer? If so, please describe.
Specific Men's
Impotence Questions
*Do you have a problem achieving or maintaining an erection
sufficient for sexual intercourse?
Yes
No
*Do you presently use Viagra® / Sildenafil Citrate
/ GSC-100?
Yes
No
*Have you ever been told you have or had congestive heart failure?
Yes
No
*Have you ever been told you have angina or other heart conditions?
Yes
No
*Do you understand that taking Viagra® / Sildenafil Citrate
/ GSC-100 while you are on a nitrate can cause your blood pressure to drop to
a potentially fatal level?
Yes
No
*Do you take nitroglycerin or any medication classified as a nitrate in any
form, including amyl nitrate (poppers)?
Yes
No
*Did you carefully complete the past medical history and indicate what medications
you are on, especially if you are taking antacids or ulcer medicine, HIV medicines,
and antibiotics because there are potentially severe medical consequences if
you don't truthfully disclose all conditions and medications?
Yes
No
In order for Generic Viagra to fill your request,
YOU MUST READ AND AGREE TO THE TERMS AND CONDITIONS
OF THIS RELEASE.
*I have read the waiver above, understand
its contents, and agree to the terms.
Yes
No
