Please answer the questions below to be eligible for your ED prescription.

Completing this questionnaire is a necessary and vital step in granting your prescription. A TIN Rx partnered doctor will review your answers and discuss them with you on your consultation call. Your doctor needs this information to determine the most appropriate treatment for you. It’s important that you are honest and respond as accurately as possible.

Upon completion of this form, you will be redirected back to your checkout process.