Full Intake Tadalafil

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Time Zone
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Disposition
Visit ID
Hello! Thank you for visiting MyDrHank. I see you're interested in Generic Cialis® (Tadalafil). Follow my prompts to get Tadalafil below.
Personal Information
Name*
May I get the first and last name of the person requesting the medication, please?
First Name Last Name
Thanks. You are one step closer! Now I need to collect a few pieces of information before we can discuss pricing. May I have the best phone number to reach you at please?
Phone*
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.*
May I have your email address? It really makes things a lot easier to send you updates on your order if you have an email, it’s ok if you don’t but if you do we’d love to be able to get that from you?
Email Address
Dr. Selection*
Great news! We can offer you 50% off your first order for subscriptions. Would you like us to contact your current Doctor or send you over to talk to our online Doctor?
- Use my current Primary Care or Urologist
- Help me find a Dr (Not available in SC 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
Telemedicine Privacy Policy
Telemedicine Informed Consent
Have you taken ED drugs 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 (Tadalafil). Most customers take one 5 milligram tablet daily for $75 a month, and you can receive 50% off 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 subscription (50% off first order)
- 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 5 tablets for $50
- 100 mg x 10 tablets for $95
- 100 mg x 20 tablets for $125
- 100 mg x 30 tablets for $150
Cialis Size - Radio*
Our most common product is generic Cialis (Tadalafil) 5 milligrams (5 mg) x 30 tablets for $75 and you can receive 50% your first month with a subscription. There is no obligation and you can cancel at any time. Which size and quantity do you prefer?
- 5 mg x 30 tablets for $75
- 10 mg x 5 tablets for $30
- 10 mg x 10 tablets for $55
- 10 mg x 25 tablets for $125
- 20 mg x 5 tablets for $50
- 20 mg x 10 tablets for $95
- 20 mg x 20 tablets for $125
- 20 mg x 30 tablets for $150
If you would like a size or quantity not listed please contact customer service at 1-888-588-8094 for the best deals and discounts.
Viagra Frequency*
With one of our monthly subscription offers you can receive 50% off your first order. How often would you like to receive them?
- One time purchase
- Monthly subscription (50% off first order)
- Every other month subscription (50% off first order)
- Every three months subscription (50% off first order)
Hidden Frequency
Hidden Drug
Hidden Size
Hidden Quantity
Hidden Subscription
Hidden Price
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 Ex: FL or Florida ZIP / Postal Code
Please make sure a valid State is entered
Unfortunately we cannot ship to this address, please enter a valid Shipping Address (not within South Carolina or District of Columbia). You may also choose to Use your Primary Care/Urologist or contact us for assistance at 888-588-8094.

You may also Click Here to select a different prescription
Hidden State
May I get your date of birth please?*
May I get your date of birth please?

Must be 18 years or older
Date Format: MM slash DD slash YYYY
Hidden DOB
DOB Pass Fail
- fail
- pass
Doctor Selection Type
- Personal
- Beluga Health
- Upscript
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
Phone Verification
- verified
- unverified
- start
Phone Verification Pass/Fail
- pass
- fail
- skip
- start
We just need to validate your phone number before we can send you messages. Please click 'Validate Phone #' below.
Sorry! We cannot send texts or multimedia messages to this Number. Please try a different number or a different contact method.
Thank you for verifying your number!
Phone
First Page Pass/Fail
- Pass
- Fail
Identity Verification
Please click the 'Start Verification' button to begin the process. If necessary we may need to ask a few questions just to verify your identity.
We do not have enough information to verify your Identity. Please make sure all fields are filled in above and click 'Start Verification' again.
We were not able to verify your Identity. Please double check your information then click 'Start Verification' again.
Thank you for verifying your Identity! You can move forward with the rest of the form.
We are unable to verify your identity at this time. Please click 'Choose File' below to upload a photo of a valid ID with your name, or Contact Customer Service at 888-588-8094.
Upload Photo ID
Accepted file types: jpg, png.
Identity Verification Status
- Verifying
- Verified
- Denied
- Cannot Verify
- Start
- Skip/Flag Verification
Error Message
Identity Question Counter

Doctor's Information
By providing your doctor’s information we can obtain approval to get your supplies delivered to you.
Please search for your Doctor using the fields below.
Please select your Doctor from the list and click This Is My Doctor below. If your Doctor is not listed, Search Again, or click Cannot Find My Doctor.
No Results Found? Click Search Again to keep searching, or click Cannot Find My Doctor to Enter Their Information
Please enter all of your Doctor’s Information including their phone number found on your most recent medication. When finished click Next at the bottom. You may also Search Again if you’d like.
Search Type
- search
- manual
- result
- confirmed
Results Found
- Yes
- No
- Empty
Select Your Doctor Here:*
Doctor's First Name*
Doctor's Last Name*
Office Location City*
Office Location State*
Office Location Zip*
Doctor's Phone Number*
Alternate Doctor's Phone Number
Thank you. Please enter your Doctor's Phone Number found on your most recent medication if it is not the same as the one listed below and please click next.
NPI Number
NNPES Full Name
NNPES Address Street
NNPES Address City State
NNPES Phone Number
NNPES Fax Number

Thank you for providing your Doctor's Information. If we have any questions regarding their information we will contact you.
Thank You! The next step involves finding a Doctor right for you.
Disposition Date

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 City State Zip Code
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
Payment Saved

Step 1 of 18

Hello! Thank you for visiting MyDrHank. I see you're interested in Generic Cialis® (Tadalafil). Follow my prompts to get Tadalafil below.

Personal Information

May I get the first and last name of the person requesting the medication, please?

Thanks. You are one step closer! Now I need to collect a few pieces of information before we can discuss pricing. May I have the best phone number to reach you at please?

May I have your email address? It really makes things a lot easier to send you updates on your order if you have an email, it’s ok if you don’t but if you do we’d love to be able to get that from you?

Great news! We can offer you 50% off your first order for subscriptions. Would you like us to contact your current Doctor or send you over to talk to our online Doctor?

Have you taken ED drugs before?

Are you interested in a once a day medication or one that you take prior to intercourse?

Great! That sounds like the best option for you would be generic Cialis (Tadalafil). Most customers take one 5 milligram tablet daily for $75 a month, and you can receive 50% off your first month with a subscription. There is no obligation and you can cancel at any time. Which do you prefer?

Our most common product is generic Cialis (Tadalafil) 5 milligrams (5 mg) x 30 tablets for $75 and you can receive 50% your first month with a subscription. There is no obligation and you can cancel at any time. Which size and quantity do you prefer?

With one of our monthly subscription offers you can receive 50% off your first order. How often would you like to receive them?

What’s the address where you’d like me to send the medication to? Can I have your street address please?

Please make sure a valid State is entered

Unfortunately we cannot ship to this address, please enter a valid Shipping Address (not within South Carolina or District of Columbia). You may also choose to Use your Primary Care/Urologist or contact us for assistance at 888-588-8094.

You may also Click Here to select a different prescription

May I get your date of birth please?

What would be your preferred contact method for us or even the Doctor to be able to contact you if necessary?

We just need to validate your phone number before we can send you messages. Please click 'Validate Phone #' below.

Sorry! We cannot send texts or multimedia messages to this Number. Please try a different number or a different contact method.

Thank you for verifying your number!

Identity Verification

Please click the 'Start Verification' button to begin the process. If necessary we may need to ask a few questions just to verify your identity.

We do not have enough information to verify your Identity. Please make sure all fields are filled in above and click 'Start Verification' again.

We were not able to verify your Identity. Please double check your information then click 'Start Verification' again.

Thank you for verifying your Identity! You can move forward with the rest of the form.

We are unable to verify your identity at this time. Please click 'Choose File' below to upload a photo of a valid ID with your name, or Contact Customer Service at 888-588-8094.

Doctor's Information

Please search for your Doctor using the fields below.

Please select your Doctor from the list and click This Is My Doctor below. If your Doctor is not listed, Search Again, or click Cannot Find My Doctor.

No Results Found? Click Search Again to keep searching, or click Cannot Find My Doctor to Enter Their Information

Please enter all of your Doctor’s Information including their phone number found on your most recent medication. When finished click Next at the bottom. You may also Search Again if you’d like.

Thank you. Please enter your Doctor's Phone Number found on your most recent medication if it is not the same as the one listed below and please click next.

Thank you for providing your Doctor's Information. If we have any questions regarding their information we will contact you.

Thank You! The next step involves finding a Doctor right for you.

Questionnaire

In order to receive your prescription your Telemedicine Doctor will only contact you through Text messages. Do you wish to use the phone number provided earlier or use a different phone number to receive SMS/Text Messages?

Please click 'Validate Phone #' below to verify that we can send SMS/Text Messages to this number.

Please enter your phone number to receive SMS/Text Messages below and then click 'Validate Phone #'

Sorry! We cannot send texts or multimedia messages to this Number. Please try a different number.

Sorry! We cannot send texts or multimedia messages to this Number. Please try a different number.

Thank you for verifying your number!

Thank you for answering our questions! You may go back to review your answers or click 'Submit Patient Info' to complete the rest of the form.

Thank you! Now, we just need to submit your patient info to the Telemedicine Doctor. You may go back to review your answers or click 'Submit Patient Info' to complete the rest of the form.

Great! Please Click 'Next' to complete the rest of the form.

There was an issue submitting your information. Please try clicking 'Submit Patient Info' again.

Thank you, please click 'Next' to continue with the rest of the form.

Questionnaire

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