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If you don't wish to order online, you can:

Print our Sildenafil Intake Form by clicking HERE.

Call or visit any Tri-State Medical Group location.

Fax your completed form to the TSMG pharmacy of your choice.

Or scan/email your completed intake form to

Your Information:

  • Pharmacy to be utilized for proper filling for RX (Follansbee Pharmacy, Value Leader Pharmacy, Tri-State Pharmacy)
  • Your First and Last Name
  • Your Address (Street, City, ZIP)
  • Your Birth date
  • Your Phone Number(s) (Home, Cell)

Your Doctor's Information:

  • First and Last Name of Doctor
  • Doctor’s Office Phone Number
  • Doctor’s Office Fax Number
  • Doctor’s Office Address (Street, City, ZIP)

Your Billing Information:

  • Indicate one: MasterCard, Visa, Discover, American Express
  • Credit Card Number
  • Credit Card Expiration Date