Order Questionnaire

Please review the the information below to verify that it is accurate. Inaccurate data will delay the processing of your order.

NEW Order Request form for LEVITRA

Patient Info:

First Name:
Middle Initial:
Last Name:
Street Address 1:
Street Address 2:
City/Town:
Outside U.S Enter Province\Region Here:
State:
Zip/Postal Code:
Country:
Email:
Phone:

Purchase Info:

Medication LEVITRA

Shipping Options Shipping prices have been adjusted to account for the FedEx fuel surcharge. Do to the volitility in the energy commodities markets jet fuel prices have risen dramatically. We will be adjusting our prices to track the changed in fuel surcharges as FedEx implements them each month. The Post Office does not (cannot) impose fuel surcharges so the price of Express Mail will not change.


*Note: Shipping time is from the time the doctor approves the order, not from the date the order is placed.

Billing Info:

We currently cannot process credit cards. Please select the COD option.
Select Card Type:

*Billing address MUST MATCH the address your bank has on file for this credit card.

Click here if the billing information is the same as the patient information.
Billing First Name:
Billing Last Name:
Billing Street Address 1:
Billing Street Address 2:
Billing City/Town:
Billing Outside U.S Enter Province\Region Here:
Billing State:
Billing Zip/Postal Code:
Billing Country:
Billing Phone:

Shipping Info:

Enter Shipping Address Here:
Click here if the shipping information is the same as the billing information.
Ship to Company:
Ship to First Name:
Ship to Last Name:
Ship to Address Line1:
Ship to Address Line2: (Optional)
Ship to Town/City:
Outside U.S enter State/Province:
Ship to State/Province:
Zip:
Ship to Country:
Ship to Phone:

General Medical Questions:

Please tell us your Medical History:
It may take some time for you to fill out this form. We know it may be frustrating to fill out such a long form, but it is important. Please take the time to answer all the question as completely as you can. Once the doctor receives this information, they will review it and either approve the prescription for LEVITRA, or decline it. If s/he declines your prescription, you will not be charged.

Enter you birthdate (mm/dd/yyyy):
/ /

Please supply the name and location of the doctor who last examined
you (optional):

First Name:		Last Name:
Town/City:		State:
Country:		Phone Number:

Please Tell The Doctor About Yourself:

Sex:

What is your height?

' "

What is your current weight in lbs?

lbs(1 kg=2.2lbs).

Smoking History:

Do you smoke cigars or cigarettes?

Yes No

If so, how many packs of cigarettes per day do you
smoke?

0 1 2 3 More

How long have you been smoking?

Do you consume more than 2 servings of alcohol a day?

Yes No

General Medical History:

Known Allergies

Have you had a physical examination within the last year?

Yes No

How is your blood pressure?

Low Normal High Don't Know

Do any diseases or disorders run in your family?

If yes, please specify:

Yes No

Do you consider anything else in your medical history to be relevant?

If yes, please specify:

Yes No

Please list all over-the-counter and prescription drugs you are currently taking and the length of time you have been taking them. (For example: Prozac - 2yrs, Claritin - 3mo, etc.)

Enter None if you are not taking any.

Are you allergic to any medications?

If yes, please specify:

Yes No

What is currently bothering you about your health?

Do you suffer from any of the following problems?

Coronary Artery Disease	Congestive Heart Failure	Valvular Heart Disease
Anatomic Deformation of the Penis	Peyronie's Disease	Multiple Myeloma
Obesity	Hypertension	Diabetes Mellitus
Prostate Cancer	Enlarged Prostate	Low Testosterone
Thyroid Disease	Atherosclerosis	Liver Disease
Kidney Disease	Stroke	Depression
Anxiety	Schizophrenia	Spinal Cord Injury
Endocrine Disorders	Sickle Cell Anemia	Leukemia
Retinitis Pigmentosa	Low or High Blood Pressure	HIV
Syphilis	Herpes	Peptic Ulcers
None

Please list all medical conditions that you are being treated for at this time.

Enter None if you are not currently being treated.

List past surgeries, e.g., Appendectomies, Heart Bypass

Enter None if you've had no past surgeries.

Questions Specific To LEVITRA
1. Are you currently taking any nitrate based medications? Physicians cannot prescribe Levitra for anyone taking nitroglycerin or organic nitrates. Nitrates are commonly used in heart medicines.	yes no
2. Do your eyes have any form of Macular Degeneration or Retinitis Pigmentosa?	yes no
3. Do you have Diabetes, Hypoglycemia or any form of blood sugar condition?
4. Do you have any form of Prostate Condition?
5. Are you unable to achieve or sustain an erection for normal sexual activity?	yes no
6. Have you even been evaluated for erectile dysfunction?	yes no
7. When did you notice a difference in your erection?
8. Have you had or presently have any heart problems?
9. Is there a history of heart disease in you family?
10. Have you had a PSA test in the last year?	yes no

Agreements:

�.

Patient Responsiblity Statement

Please read and agree to the terms of this Statement.

I am seeking treatment for a medical condition and I understand that no drug, even if prescribed by a physician, is guaranteed to improve my conditions.

I am an adult and of my own choice am selecting GetSmartViagra as my agent for collecting and transmitting my medical data to a physician for review and to fill the precription and any refills at a pharmacy of its choice.

I hereby release GetSmartViagra, it employees, contractors, physicians and pharmacists of any and all liability associated with this consultation and/or the use of this drug.

I will answer each question accurately and truthfully. I understand that physicians and pharmacist will review this questionnaire and can only perform an effective evaluation of my medical history if it is complete and accurate.

I understand that there is no guarantee that a physician or a pharmacist will approve my request for treatment with this drug.

I am aware that there may be side effects associated with this or any pharmaceutical drug.

I agree to assume any and all responsibility or liability arising from the use of this drug.

I have had a recent physical examination and I have no knowledge of any disease or condition that would make this drug inappropriate for me to use..

I will notify my personal physician of my use of this drug and discontinue its use if so recommended by my physician.

I will pay all shipping costs, customs duties, tarrifs and taxes, if any, which are applicable in the country where this product is to be shipped.

I understand that pharmaceuticals, after they have been shipped, may not be returned for a refund. Once shipped, all sales are final.

I agree to personally sign for this product when it is delivered. I agree to immediately inspect the shipment and notify the carrier of any problems before signing for the shipment. If I waive the signature or have a signature on file with the shipper I assume total responsibility for lost, missing, or damaged shipments.

Please acknowledge your agreement to this waiver by clicking the 'I Agree' button below.

I Agree

I would like to receive promotional email with information about health tips, new site features and special product promotions.

Comments : Please tell us where you found this site
and you will get $1.00 (U.S.) off of your order

Example: Yahoo search, AOL search, MSN, Email, referred by
friend, television, or radio. Thanks for the help.

You are about to place an order, please click�the Order button only once. This may take a minute or two to process.

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