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Men’s Sexual Health

Medication Refill Form

Please Fill Out the Fields Below

We can assist you with prescription refills even if you were previously seen at another clinic.

Name*


First


Last

Phone*

Email*

Medication Type*

InjectionSublingual (Under the Tongue)

Additional Information*

*Disclosure: Our medical practice is not affiliated with any previously existing erectile dysfunction/premature ejaculation medical clinics or pharmacies.