Enroll - UBI Telehealth

First up

Answer a few questions so we can help

In which state do you currently reside?

State is required

We regret to inform you that we do not currently offer shipping to your state of residence. We are not available in the following states: AL, AK, AR, CA, CO, DE, HI, ME, OK, SC, SD, WV, WY. We apologize for any inconvenience and appreciate your understanding.

What is your Date of Birth?

mm/dd/yyyy

This field is required Please enter valid date

Thank you for visiting UBI Telehealth. Our products are intended only for those who are 18 years of age or older, in accordance with legal and medical guidelines. Please consult with your primary care provider for a personalized treatment plan that is both safe and effective for you. We invite you to browse our other available products, as there may be an alternative that better suits your needs.

What was your sex assigned at birth?

Male

Female

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Thank you for visiting UBI Telehealth. This workflow pertains to male erectile dysfunction. Please refer back to product list for women.

Are you currently pregnant or breastfeeding?

Yes

This field is required

Thank you for visiting UBI Telehealth. This product shouldn't be used if you are currently pregnant or breastfeeding. Please consult with your primary care provider for a personalized treatment plan that is both safe and effective for you. We invite you to browse our other available products, as there may be an alternative that better suits your needs.

Patient Attestation

I hereby declare that I have read and understood the following terms and conditions related to obtaining an online prescription:

Telemedicine Consultation: I understand that the prescription will be provided to me based on an online consultation with a qualified healthcare professional. I acknowledge that this consultation may take place via video call, phone call, or secure messaging platform.

Accurate Information: I certify that all the information provided during the consultation, including my medical history, current medications, allergies, and other relevant details, is accurate and complete to the best of my knowledge.

Informed Consent: I acknowledge that the healthcare professional will rely on the information provided by me to make clinical decisions and prescribe medication. I understand the benefits, risks, and potential side effects of the prescribed medication and have had the opportunity to ask questions or seek clarification.

Prescription Validity: I acknowledge that the prescription provided to me is valid for the specified duration as determined by the prescribing healthcare professional. I understand the importance of regular follow-ups and will schedule appropriate appointments as recommended.

Responsible Use: I will use the prescribed medication solely for my personal use and in accordance with the healthcare professional's instructions. I will not share the medication with others or use it for any purposes other than its intended use.

Safety and Monitoring: I understand the importance of monitoring for any adverse reactions or unexpected changes in my health while taking the prescribed medication. I will promptly report any concerns or side effects to the healthcare professional.

Compliance with Regulations: I acknowledge that the online prescription process is subject to applicable local laws, regulations, and guidelines. I will comply with all legal requirements related to obtaining and using the prescription.

Disclaimer: I understand that the online prescription is based on the information provided during the consultation and does not replace an in-person examination by a healthcare professional. I agree to assume full responsibility for any consequences arising from the use of the prescribed medication.

I hereby declare that I have carefully read and understood the above terms and conditions. I agree to abide by them and acknowledge that any failure to comply may result in the invalidation of the prescription.

By selecting the checkbox, you are providing your digital signature as an indication of your agreement.

This field is required

Date: 09/19/2024

How often do you have trouble getting or keeping an erection during sex?

Always

Sometimes

Occasionally

Rarely

This field is required

What outcomes are you aiming for?

Achieving and maintaining an erection during sexual activity

Improve Libido

Both of the above

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Over the past six months, how sure are you that you could get and keep an erection?

Very Low

Low

Moderate

High

Very High

This field is required

Over the past six months, when you had erections, how often were they strong enough to START sex?

Almost never or never

Much less than half the time

About half of the time

Much more than half of the time

Almost always or always

This field is required

Over the past six months, when you had erections, how often were they strong enough to CONTINUE sex?

Almost never or never

Much less than half the time

About half of the time

Much more than half of the time

Almost always or always

This field is required

In the last 6 months, how difficult was to reach orgasm?

Extremely difficult

Very difficult

Difficult

Slightly difficult

Not difficult

This field is required

How often did you enjoy sex in the last 6 months?

Almost never or never

Much less than half the time

About half of the time

Much more than half of the time

Almost always or always

This field is required

Your answers to the questions indicate that you have no erectile dysfunction and you would not be a candidate for ED medications at this time. Please feel free to browse through some of the other products or services you might be interested in.

Please consult with your primary care physician for other options.

Have you had a physical exam from your physician in the last 3 years?

Yes

This field is required Please consult with your primary care physician for this treatment.

What is your last systolic blood pressure (top number)?

90 to 160 mmHg

Less than 90 mmHg

161 mmHg or higher

This field is required Please consult with your primary care physician for this treatment.

Are you taking sublingual nitroglycerine/nitrates for chest pain?

Yes

This field is required

Do you have a history of any of the following:

None of the below

Peyronie's disease or other disorders of penile deformity

History of priapism

Sickle cell disease

Active stomach ulcer

History of Retinitis Pigmentosa

History of visual loss related to disease of optic nerve such as optic neuritis

History of liver disease (including cirrhosis)

History of kidney (renal) impairment

This field is required

Are you on any of the following medications?

Amiodarone (Cardarone, Pacerone)
Pimozide (Orap)
Riociguat(Adempas)
Sotalol (Betapace, Sorine, Sotylize)
Ibutilide (Corvert)
Nitroglycerine
Nitroprusside
Thioridazine (Mellaril)
Vericiguat (Verquvo)
Dronedarone (Multaq)

Quinidine (Quinaglute, Quinidex)
Iefamulin (Xenleta)
Abilify
Procainamide (Pronestyle, Procan, Procanbid)
Accupril (Quinapril)
Disopyramide (Norpace, Rhythmodan)
Isosorbide dinitrate
Isosorbide mononitrate
Iefamulin (Xenleta)

Yes, I am taking one or more of these medications

You are not a candidate because you are taking some medications that cannot be taken with the ED treatment we offer. Please consult with your primary care physician for other options.Thank you for your interest.

This field is required

List your Medication Allergies

No known allergies

Please list any allergies you have?

This field is required

Have you taken Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra), or Avanafil (Stendra) in the past?

Yes

This field is required

Please type in name of the medication you have previously taken for ED and dosage?

This field is required

Was the medication effective?

Yes

This field is required

Did you have undesirable side effects or allergic reaction?

Yes

This field is required

Please list any side effects you experienced

This field is required

What is your zip code?

Enter your zip code:

Zip is required Enter valid zip code

Thank you for visiting UBI Telehealth. This workflow pertains to male erectile dysfunction. Please refer back to product list for women.

Do you smoke?

Yes

This field is required

How many packs a day

Less than half ppd

Half ppd

One ppd

More than one ppd

This field is required

For how long?

Less than one year

1-5 years

5-10 years

More than 10 years

This field is required

Do you regularly consume more than two alcoholic beverages per day?

Yes

This field is required

Do you often consume more than 14 alcoholic beverages per week?

Yes

This field is required

Have you been advised by your physician to avoid excessive physical activity?

Yes

This field is required

In the past three months, have you had chest pain that limits your physical activity?

Yes

This field is required

First up

In which state do you currently reside?

We regret to inform you that we do not currently offer shipping to your state of residence. We are not available in the following states: AL, AK, AR, CA, CO, DE, HI, ME, OK, SC, SD, WV, WY. We apologize for any inconvenience and appreciate your understanding.

What is your Date of Birth?

What was your sex assigned at birth?

Thank you for visiting UBI Telehealth. This workflow pertains to male erectile dysfunction. Please refer back to product list for women.

Are you currently pregnant or breastfeeding?

Patient Attestation

How often do you have trouble getting or keeping an erection during sex?

What outcomes are you aiming for?

Over the past six months, how sure are you that you could get and keep an erection?

Over the past six months, when you had erections, how often were they strong enough to START sex?

Over the past six months, when you had erections, how often were they strong enough to CONTINUE sex?

In the last 6 months, how difficult was to reach orgasm?

How often did you enjoy sex in the last 6 months?

Your answers to the questions indicate that you have no erectile dysfunction and you would not be a candidate for ED medications at this time. Please feel free to browse through some of the other products or services you might be interested in.

Please consult with your primary care physician for other options.

Have you had a physical exam from your physician in the last 3 years?

What is your last systolic blood pressure (top number)?

Are you taking sublingual nitroglycerine/nitrates for chest pain?

Do you have a history of any of the following:

Are you on any of the following medications?

You are not a candidate because you are taking some medications that cannot be taken with the ED treatment we offer. Please consult with your primary care physician for other options.Thank you for your interest.

List your Medication Allergies

Have you taken Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra), or Avanafil (Stendra) in the past?

Please type in name of the medication you have previously taken for ED and dosage?

Was the medication effective?

Did you have undesirable side effects or allergic reaction?

What is your zip code?

Thank you for visiting UBI Telehealth. This workflow pertains to male erectile dysfunction. Please refer back to product list for women.

Do you smoke?

How many packs a day

For how long?

Do you regularly consume more than two alcoholic beverages per day?

Do you often consume more than 14 alcoholic beverages per week?

Have you been advised by your physician to avoid excessive physical activity?

In the past three months, have you had chest pain that limits your physical activity?

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