Electronic Medical Consultation - TriMix Reversal

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

Shipping Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

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

Do you have an allergy to a particular medication?

Yes, I have a history of drug allergies
No known drug allergies

How long have you been experiencing symptoms of erectile dysfunction?

Recently
Several months
More than a year
Several Years

Are you able to achieve an erection without any assistance of medications?

Yes
No

How frequently do you experience difficulty in maintaining an erection?

Rarely
Occasionally
Frequently
Always

How often do you achieve orgasm with sexual stimulation?

Never
Frequently
Always

Have you ever experienced priapism? (prolonged erections lasting more than four hours)

Yes
No

Are you using any Alpha Blockers (ex. Tamsulosin, Flomax)?

Yes
No

Have you ever had prostate issues or been diagnosed with benign prostatic hyperplasia (BPH)?

Yes
No

Are you currently taking TriMix Injections?

Yes
No

Is Viagra, Cialis, or any Oral ED tablets working for you currently?

Yes
No
Have not tried oral medications.

Are you currently taking or have you previously taken medication for ED?

Yes
No

How long do your erections typically last?

Do you smoke or have a history of smoking?

Yes
No

How many alcoholic drinks do you consume a week?

1 to 2 drinks per week.
3 to 5 drinks per week.
7 to 14 drinks per week.
15 drinks or more per week.

Patient Assertation

I attest that I am the patient identified at the top of this form and that I am completing this questionnaire truthfully and of my own free will for my personal medical care. I understand that the information I provide will be reviewed by a licensed healthcare provider for the purpose of determining whether a prescription is appropriate.

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 or MisterMeds.com

Yes, I agree

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Trimix for Erectile Dysfunction: Benefits, Results & How to Get It Online

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