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Complete this form to have menMD request a RX from your provider.
Date of Birth
*
Gender
*
Male
Female
Other
Prefer not to say
Subject
*
Your Name
*
Your Email
*
Drug Name and Strength
None
Anastrozole Tablets
Bremelanotide (PT141) Lozenges for HSDD
Clomiphene Capsules
Estradiol Cream for Female Sexual Dysfunction
Finasteride Tablets for BPH/Hair Loss
Glucagon-like Peptides (Semaglutide,Liraglutide, Tirzepatide, Dulaglutide)
Intraurethral Gel
Minoxidil/Finasteride Solution for Hair Loss
Other
Oxytocin Tablets
Pentoxifylline Tablets for Peyronie's Disease
Phenylephrine for Prolonged Erections
Scream Cream for Female Sexual Dysfunction
Sermorelin Injection
Sermorelin Lozenges
Sildenafil Tablets (Active Ingredient in Viagra)
Tadalafil Tablets or Lozenges (Active Ingredient in Cialis)
Tadalafil/Finasteride for BPH
Tamsulosin Capsules for BPH
Tamsulosin/Tadalafil for BPH
Testosterone Cypionate Injection
Testosterone Gel
Testosterone Pellets
Testosterone Rapid Dissolve Tablets
Trimix/Bimix/Quadmix ICI Injections
Valacyclovir Tablets for Herpes
Vardenafil Lozenges
Verapamil Cream for Peyronie's Disease
Other Drugs & Treatment Plan Notes
Provider's First Name
*
Provider's Last Name
*
Provider's Phone Number
*
Provider's Address
*
SUBMIT