Female Sexual Health Consultation - Peaks Curative

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Sexual Health
Wellness
Weight Loss
Hair Growth
Skin Care
Bundles

Thank you for your order.

Please fill out the questionnaire so a Peaks Curative medical professional can review your information.

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Patient Name *

First

Middle

Last

What was your sex assigned at birth? (This product will only be prescribed to female patients). *

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 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

Do you have any allergies or hypersensitivity to aminophylline, arginine or sildenafil or any other medication? *

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

List all the medicines you are allergic to. *

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. *

Do you have any of these conditions? *

Heart disease
Blood disorder (leukemia or myeloma)
Diabetes
Liver or kidney diseases
Sickle cell
None of these diseases

Do you take any of these medications? *

Nitroglycerin. isosorbide dinitrate or mononitrate
Terazosin. Doxazosin or Tamsulosin
Alfuzosin or Silodosin
Fluconazole
None of these medications

Which of these medical conditions apply to you? *

Low libido (lack of interest in sex)
I drink alcohol excessively
I have problems within my relationship
I suffer from depression, anxiety, bipolar, psychosis or other psychiatric disorders
None

When did your symptoms start? *

Less than 6 months ago
6-12 months ago
Over a year ago
Symptoms started at a young age (before the age of 21)
I have no symptoms

Are you currently taking or have you previously taken medication for sexual dysfunction? *

Yes
No

What medications have you taken or are currently taking for sexual dysfunction?

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.

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

Are you pregnant, planning to become pregnant, or currently breastfeeding? *

Yes
No

Warning (Scream Cream): *

I understand that as with any medication, there is a risk 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 Scream Cream 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 and reapplied afterwards.

Warning (Arousal Melts): *

I understand that I must not take Viagra or Cialis with Nitroglycerin. isosorbide dinitrate or mononitrate, terazosin, doxazosin, tamsulosin, alfuzosin, and silodosin or fluconazole to avoid severe adverse reaction

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 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

Leave a comment or feedback

Disclaimer: The information provided regarding Peaks Curative compound offerings are for compounded formulations and are NOT an FDA-approved drug label. The suggested formulations are provided for reference only and are based on formulations that have historically been ordered by duly licensed professionals. Compounded products are exempt from FDA approval and no claims are made to the safety and efficacy of any compounded product for any indication or specific use.

Prescribing of the compounds must be based upon the professional judgment of the licensed health care provider after considering the patient’s unique medical condition and factors including body weight, size and overall health status. No liability attaches in any way to any actual or alleged injury to any person or any damage to any tangible property if the compounded product is used beyond the scope as prescribed by your physician.

The licensed pharmacist and/or licensed physician maintains the responsibility to ensure compliance with Section 503A of the Food, Drug and Cosmetic Act, including the requirement that a compound be dispensed pursuant to a valid prescription, from a licensed prescriber, for an identified individual patient. The licensed pharmacist and/or licensed physician is also responsible for ensuring that none of the ingredients appear on an exclusion list maintained by the FDA, and that all the ingredients may be lawfully used in pharmacy compounding.

Optimize Your Health for Success Now

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Discover Confidence, Comfort, and Convenience with Peaks Curative – Your Gateway to Doctor-verified telehealth treatments for men & women. Discreetly Delivered to Your Doorstep

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Clitoral stimulation cream

Libido booster for women

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Scream Cream for arousal

Female pleasure cream

Topical arousal cream

Increased sensitivity for women

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Women’s Sexual Health
Men’s Sexual Health
Weight Loss
Hair Growth For Men

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Call: (878) 732-5669

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FAQ
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Learn
Return & Refund Policy
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Terms and Conditions

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