LABOR DAY SALE! USE CODE
PEAK30
FOR A 30% Discount on ALL of our products.
OFFER ENDS SEPT. 16
Weight Loss
For Men
Men’s Sexual Health
Hair Loss
For Women
About
Blog
Contact us
Menu
Weight Loss
For Men
Men’s Sexual Health
Hair Loss
For Women
About
Blog
Contact us
$
0.00
0
Cart
Search
Search
Close this search box.
Weight Loss
For Men
Hair Loss
Men’s Sexual Health
For Women
About
Blog
Contact Us
My account
Menu
Weight Loss
For Men
Hair Loss
Men’s Sexual Health
For Women
About
Blog
Contact Us
My account
$
0.00
0
Cart
Search
Search
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 7
Patient Name
*
First
Middle
Last
What was your sex assigned at birth?
*
Male
Female
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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 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.
I am capable of making sound medical decisions
*
Yes
No
Previous
Next
Do you have any allergies or hypersensitivity to aminophylline, arginine or sildenafil?
*
Yes
No
List all the medicines you are allergic to.
*
Previous
Next
Do you have hypertension?
*
My blood pressure is normal (lower than 130/90)
I have elevated blood pressure (greater than 160/100)
Are you currently taking any blood pressure lowering medications?
*
Yes
No
List all the blood pressure lowering medications and dosages you take, including over-the-counter drugs.
*
Previous
Next
Do you have any cuts, open lesions, recent surgical incisions, or episiotomies in the vaginal area?
*
Yes
No
You should not use Scream Cream until cuts, incisions, lesions, episiotomies have healed, and sutures have dissolved. If you have any questions fill out below.
Previous
Next
Warning:
*
I understand that as with any medication, there is a risk for a male partner to experience an allergic reaction to any of the ingredients after coming into contact with the topical cream. Additionally, if a male partner is taking nitrates, they would be at risk with the sildenafil; avoid exposure to any open wounds or active infections.
*
Do not not use prior to oral sex. Sildenafil is a prescription medication and should not be ingested orally, unless prescribed for oral use. However, once the medication has taken effect, it may be cleaned off with a body wipe to proceed with oral sex.
Field #76 (copy)
*
Do not use more than 4 times in 24 hours.
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 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
Leave a comment or feedback
Submit
Search
✕