MultiMeds.....
 The most reliable pharmaceutical service
<

Please fill in the following information as completely and accurately as possible to issue you with your prescription. There are 6 easy steps to complete this form. This is a secure form using SSL. Please note that If you are NOT approved, you will NOT be charged for the consultation. Your prescription will be charged to your credit card and dispensed by our affiliated pharmacy if you are approved for this medication.

Please NOTE!! when selecting checkboxes Means YES and Means NO.

If referred by a friend enter their consult ID
 
MultiMeds.....
 The most reliable pharmaceutical service
Non Prescription Store
1) Your Viagra Order
If you are an existing client and need a refill

I Request the following prescription:


(Select your pill order from the dropdown box above)
After your initial order you can get 5 refills with NO consulting fee. Valid for 6 months
If I am approved for Viagra ¨, I would like my prescription to be charged to my
credit card and dispensed by your affiliated pharmacy.
Splitting the 100mg dose can result in a cost of only $5.00 per 50mg dose!!
2) Shipping Instructions
Deliver my prescription using the following shipping method:


Please NOTE!!! Shipment is AFTER doctor approval.
NOTE!! Deliveries sent on Friday Overnight will be delivered on MONDAY.
Please ensure that someone is around to receive your prescription.
 International Orders ONLY
You agree to assume all liability for any customs, duties, or tariffs for your destination country.
Should customs impound the shipment, we cannot refund your cost.
If it is returned to us, you will be charged for shipping both ways.
I AGREE TO INTERNATIONAL WAIVER (intl. shipping only)
3) Payment Information
Only the Applicants or Applicants Family credit cards are accepted.
Select Card Type:

Are you currently taking any medication / s?
If yes enter them here:
6) Viagra Specific Questions

The following questions are to inform us of any possible medical contraindications you may have to taking Viagra ¨. Accurate information is required before any physician could treat you for any illness or condition.
In the following questions, the term erectile dysfunction means the inability to achieve or sustain an erection that is adequate for normal sexual activity.

What currently health problems are you having?
Are you unable to achieve and sustain an erection that is adequate for penetration until orgasm?
Have you ever been evaluated for erectile dysfunction?

I feel that I am incapable of having normal satisfying sex without prescription medication.

Are you currently taking any form of NITRATE Medication?
If yes, please specify:

Declaration
By submitting this consultation form I hereby certify that: Agree
I am 18 years of age or older.
I am permitted by law to receive these products in my region/country/locale .
I have read and understand the potential side-effects of this medication.
I do not have a current prescription for this medication from another physician.
I am allowed by law to use the credit card used to place this order.
My credit card will be billed $75.00 by MultiMeds.Com, Inc. if I am issued with a prescription.
I have answered all the questions truthfully.
I have read and agree with the page below

Finish Your Order Thank You for your time.

Please NOTE!!!
Your Credit card will be billed by: MultiMeds.Com, Inc.
Once a prescription is issued and it is sent out for delivery, it is ILLEGAL for us to accept the
prescription back into stock. ALL deliveries sent are for signature so please ensure some-one
is available to accept the package. Any medication returned will NOT be subject to any refunds.

All trademarks and registered trademarks are of their respective companies.
Last updated July 30, 2000
Waiver
Copyright 1999 Multimeds©, All Rights Reserved