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Weight Loss
Sexual Health
For Men
Peak Gummies & Melts
Generic Tablets
For Women
Hair Growth
Skin Care
Learn
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Weight Loss
Sexual Health
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Peak Gummies & Melts
Generic Tablets
For Women
Hair Growth
Skin Care
Learn
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Menu
Weight Loss
Sexual Health
For Men
Peak Gummies & Melts
Generic Tablets
For Women
Hair Growth
Skin Care
Learn
My account
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Step
1
of 12
Patient Name
*
First
Middle
Last
What was your sex assigned at birth? (Patients need to be male to get a prescription).
*
Male
Female
Date of Birth
*
MM
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YYYY
2025
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Shipping Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
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Texas
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Vermont
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State
Zip Code
Phone (A number able to receive text messages is best)
*
Email
*
Next
Online 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 Peaks Curative 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.
I am capable of making sound medical decisions
*
Yes
No
Previous
Next
Do you have an allergy to a particular medication?
*
Yes, I have a history of drug allergies
No known drug allergies
List all the medicines you are allergic to.
*
Previous
Next
Do you have any of these conditions?
*
Deformation of the penis
Heart disease
Blood disorder (leukemia or myeloma)
Diabetes
Liver or kidney diseases
Low testosterone level
Sickle cell
None of these diseases
Previous
Next
Do you have hypertension?
*
My blood pressure is normal (lower than 130/90)
I have elevated blood pressure (greater than 160/100)
Previous
Next
Do you take any of these medications?
*
Nitrates. nitroglycerin. isosorbide dinitrate or mononitrate
Terazosin. Doxazosin or Tamsulosin
Alfuzosin or Silodosin
Fluconazole
None of these medications
Previous
Next
Which of these medical conditions apply to you?
*
Low libido (lack of interest in sex)
Premature ejaculation
Erectile dysfunction
I drink alcohol excessively
I have problems within my relationship
I suffer from depression, anxiety, bipolar, psychosis or other psychiatric disorders
None
Previous
Next
When did your symptoms start?
*
Less than SIX months
6-12 months ago
Over a year ago
Symptoms started at a young age (before the age of 21)
I have no symptoms
Previous
Next
Are you currently taking or have you previously taken medication for ED?
*
Yes
No
What medications have you taken or are currently taking for ED.
*
Previous
Next
When was your last in-person doctor visit?
In the last 3 months
In the last 3 to 6 months
In the last 6 to 12 months
Over 12 months ago
Have NEVER seen a doctor in-person
Previous
Next
Treatment 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 reaction
Previous
Next
Patient Assertation
*
I hereby certify that, to the best of my knowledge, the provided information is true and accurate.
Medication Disclosure Clause
*
I hereby 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.
Prescription will be fulfilled by RxCompoundStore.com.
*
Yes, I agree
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