Online ED Medication Request

Please Select Your Nearest OMC Location

Bend
Eugene

Do you have any of the following medical problems?

High blood pressure

Yes
No

Pulmonary Hypertension

Yes
No

Type 2 diabetes

Yes
No

Type 1 diabetes

Yes
No

History of heart attack or heart failure

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Hardening of the arteries

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Poor blood circulation

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Severe low blood pressure

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

History of syncope

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

History of liver disease

Yes
No

Surgery or radiation to the prostate gland

Yes
No

Neurological disease like MS or spinal cord trauma

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Abnormal heart rhythms

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Acquired or congenital heart defects, valve problems or murmurs

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

High cholesterol

Yes
No

History of organ transpant (kidney, liver, heart, etc)

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

If you have any other medical problems, please list them below.

Do you have any Drug Allergies? (yes/no)

Yes
No

If yes, which drugs?

What was the last blood pressure recorded in your doctors office?

Systolic:

Diastolic:

Do you ever experience any of the following symptoms?

Chest pain either at rest or with exercise

Yes
No

You have medical history that automatically disqualifies you from being a candidate for ED medication. If desired, please contact our office today to schedule an appointment.

Schedule an Appointment

Shortness of breath with minimal activity

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Pain or cramping in the legs with exercise (claudication)

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Palpitations or irregular heart beats

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Unexplained light-headedness or passing out.

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Do you use any of the following drugs or medications?

Nitrates (isosorbide dinitrate, nitroglycerine, BiDil, etc.)

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Erythromycin

Yes
No

Cocaine

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Methamphetamines

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Clarithromycin

Yes
No

Ketoconazole

Yes
No

Ritonavir

Yes
No

Cimetidine

Yes
No

Rifampin

Yes
No

alpha-blockers (doxazosin, terazosin, hydralazine)

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Amyl Nitrate or Butly Nitrate

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Poppers or Rush

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Molly (MDMA, ecstacy)

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Adempas (Riociquat)

Yes
No

You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician.

Have you used any ED medications in the past?

Yes
No

If yes, which ones?

Sildenafil (Viagra, Revatio)
Tadalafil (Cialis)
Vardenafil (Levitra, Staxyn)
Avanafil (Stendra)
Other

If you selected "Other" above, please list them below:

Did you experience any side effects?

Yes
No

If yes, then what where they?

How often to you anticipate using medication for ED?

Daily
Weekly
Monthly
Other

If you selected "Other" above, please elaborate below:

ADAM Questionnaire

Do you have a decrease in libido (sex drive)?

Yes
No

Do you have a lack of energy?

Yes
No

Do you have a decrease in strength and/or endurance?

Yes
No

Have you lost height?

Yes
No

Have you noticed a decreased "enjoyment of life”?

Yes
No

Are you sad and/or grumpy?

Yes
No

Are your erections less strong?

Yes
No

Have you noticed a recent deterioration in your ability to play sports?

Yes
No

Are you falling asleep after dinner?

Yes
No

Has there been a recent deterioration in your work performance?

Yes
No

If you answered Yes to 3 or more ADAM Questions, please schedule an appointment for a free T-Screening at OMC.

Schedule an Appointment

Do you have or suspect you have low testosterone?

Yes
No

Given that you have, or suspect you have, low testosterone, please schedule an appointment with us.

Schedule an Appointment

You are a Candidate for ED Medication

Which Medication Would You Like to Order?

10 Tablets of Tadalafil (Generic Cialis): $150
10 Tablets ot Sildenafil (Generic Viagra): $100

Your Total is $150

Please fill out your information below and visit our Bend office to pay for and pick up your medication.

Your Total is $150

Please fill out your information below and visit our Eugene office to pay for and pick up your medication.

Your Total is $100

Please fill out your information below and visit our Bend office to pay for and pick up your medication.

Your Total is $100

Please fill out your information below and visit our Eugene office to pay for and pick up your medication.

Full Name

Email Address

Phone Number

Is there anything else OMC needs to know about your health?