Call Center Outbound 2

Time Zone
Session ID*
Using ED?*
Great, let me ask you a few questions, are you currently using erectile dysfunction medication or interested in starting?
- Yes
- No
- Not sure
Someone Else*
Do you have someone you love that you are calling for to get assistance with this issue?
- Yes
- No
Personal Information
Name*
May I get the first and last name of the person requesting the medication, please?
First Name Last Name
Phone*
Phone Number
First Consent
You give consent for Dr Hank to call me at this number if you have any issues with this form.

You accept the Terms and Conditions.
Email Address
Dr. Selection*
Before we show you pricing, we can offer 50% off of your first order for subscriptions if we use your current doctor . Would you like us to contact them or send you over to talk to our online doctor on the phone.
- Use my Dr and save 50%
- Help me find a Dr (Not available in NC, SC, MT, ND, and DC)
Consent*
I agree to these terms
You consent to being treated via telemedicine and being contacted via email, phone, or text. For more details regarding this consent you can visit mydrhank.com
Taken Before*
Have you taken ED drugs before?
- Yes
- No
Daily or Prior*
Are you interested in a once a day medication or one that you take prior to intercourse?
- Daily
- Prior to intercourse
Chose Daily*
Great! That sounds like the best option for you would be generic Cialis. Most customers take one 5 milligram tablet daily for $75 a month, and you can receive 50% your first month with a subscription. There is no obligation and you can cancel at any time. Which do you prefer?
- One time purchase
- Monthly
- Other med size or quantity
Chose prior to intercourse*
Our most common product is generic Viagra 20 milligrams - 25 tablets for $47.50. and you can receive 50% your first month with a subscription. There is no obligation and you can cancel at any time. Which do you prefer?
- One time purchase
- Monthly
- Every other month
- Every three months
- Other med size or quantity
Viagra or Cialis*
We sell generic Viagra and generic Cialis. Which are you interested in?
- Viagra
- Cialis
Viagra Size - Radio*
Which milligram size and how many tablets? Our options are:
- 20 mg x 25 tablets for $47.50
- 20 mg x 50 tablets for $90
- 50 mg x 10 tablets for $50
- 50 mg x 20 tablets for $95
- 100 mg x 10 tablets for $95
- 100 mg x 20 tablets for $125
- 100 mg x 30 tablets for $150
Viagra Size*
Which milligram size and how many tablets? Our options are:
Cialis Size*
Which milligram size and how many tablets? Our options are:
Cialis Size - Radio*
Which milligram size and how many tablets? Our options are:
- 5 mg (taken daily) x 30 tablets
- 20 mg x 5 tablets
- 20 mg x 10 tablets
- 20 mg x 20 tablets
- 20 mg x 30 tablets
If patient wants a size or quantity not listed refer to customer service.
Viagra Frequency*
How often would you like to receive them?
- One time purchase
- Monthly
- Every other month
- Every three months

What’s the address where you’d like me to send the medication to? Can I have your street address please?
Shipping Address
Street Address City State Zip Code
May I get your date of birth please?*
Date Format: MM slash DD slash YYYY
Preferred Contact Method*
What would be your preferred contact method for us or even the Doctor to be able to contact you if necessary?
- Phone
- Text
- Email

We will reach out to your doctor on your behalf and request approval for this medication
Can I get your Doctor’s last name please?*
Last Name is required, if they don't know it suggest it would be on a prescription bottle if they have one. We cannot move forward using their doctor if they don't know their name. Try hard to get the first name as well.
Do you know their first name by chance?
How about their phone number?*
And are they in the same city as you?*
- Yes
- No
What City is your doctor in?*

Please list all medications you are currently taking, including both prescription and over-the-counter medications.*
Please list any serious illnesses you currently have or have had in the past.*
Please list any current allergies you have or have had in the past.*
For none enter none.

I hereby waive pharmacist counseling at this time. I understand that if I have any questions, a pharmacist is available for consultation.*
I understand
Did you answer all medical questions truthfully?*
- Yes
- No
We will need to go back and fix your answers, do recall which questions were untruthful?

We are almost done. We pay for the doctor visit but we do collect payment information now so once they approve we can ship you out immediately. You will not be charged if you are not approved. Can I please get a 16 digit card number from you please?
We are almost done. You will not be charged until we received approval from your doctor but we do collect payment information now so once they approve we can ship you out immediately. You will not be charged if you are not approved. Can I please get a 16 digit card number from you please?
Credit Card Number
Expiration Date
The expiration date?
And is the billing address the same as the shipping address? if not collect billing address.
Billing Address Check
- Billing address is the same as shipping
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Audio States (CA, HI, IL, IN, IA, KS, KY, LA, MD, MA, MI, MS, MT, NJ, OH, OK, OR, PA, RI, SD, TX, UT, VA, WY)
The doctor will be calling you confirm you are wanting this medication and if they have any more questions. Be on the lookout from a phone call coming from a Utah or Arizona area code.
Video State (AL, AZ, AR, DE, MO, ID, NV, NH, NM, VT, WV)
You will need to complete a video conference required by your state laws. We will have a support specialist contact you to give you login information and schedule the conference.
Digital States (CO, CT, FL, GA, ME, MO, NE, NY, TN, WA, WI)
Rarely the Doctor will call to confirm you are wanting this medication and if they have any more questions. If you get a call from a Utah or Arizona area code, answer it just in case.
Once we have the approval from the Dr we will bill your CC and get your medication shipped out. If you have any further questions. Please feel free to contact us at 1-888-588-8094

Step 1 of 13

Personal Information

Questionnaire

Viagra

Cialis

Levitra

Stendra