ED Treatment Intake Form

Personal Information

First Name *

Last Name *

Email *

Phone *

Date of Birth *

State of Residence *

Shipping Address (for medication delivery) *

City *

ZIP Code *

Medical History

How long have you experienced erectile difficulty? *

Less than 6 months 6 months to 1 year 1–3 years More than 3 years

How would you describe your symptoms? *

Mild — occasional difficulty Moderate — frequent difficulty Severe — unable to achieve or maintain

Have you tried ED medication before? *

No, never Yes, and it worked Yes, but only partially effective Yes, but it did not work

If yes, which medications and doses?

Do you have any of the following conditions? (Select all that apply)

Diabetes High blood pressure Heart disease or history of heart attack History of stroke Low testosterone Depression or anxiety Prostate condition (BPH, prostatitis, prostate cancer) Peyronie’s disease None of the above

Previous surgeries (list any)

Medications & Allergies

Current medications (list all, including supplements) *

Are you currently taking any of the following? *

Nitrates (nitroglycerin, isosorbide) — for chest pain/heart Alpha-blockers (tamsulosin, doxazosin) — for prostate/BP Blood thinners (warfarin, Eliquis, Xarelto) HIV protease inhibitors None of the above

Drug allergies *

Which medication are you interested in?

Tadalafil (daily or as-needed, lasts up to 36 hours) Sildenafil (as-needed, fast onset 30–60 min) Not sure — I’d like Dr. Robbins to recommend

Consent & Schedule

I have read and agree to the Telehealth Informed Consent above. *

I acknowledge the Privacy Policy and consent to the collection and use of my health information as described. *

I confirm that I am 18 years of age or older and a current resident of Florida. *

Consultation fee: $50 — payable at time of scheduling

You will be redirected to schedule your telehealth visit after submission.

Confidential Intake Form

Personal Information

Medical History

Medications & Allergies

Consent & Schedule