Reorder Form Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Phone*Email* Sildenafil - 150mgSIL TrocheSIL Rapid Desolving Tablet (RDT)QuantityVardenefil - 75mgVAR TrocheVAR Rapid Desolving Tablet (RDT)QuantityTadalafil - 6.25mg / 75mgTAD 6.25mg TrocheTAD 6.25mg RDTTAD 75mg TrocheTAD 75mg RDTQuantityTrimix - Injectable MedicationTrimixQuantity
