Sexual Wellness

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🧍 Personal Information

Name *

First

Last

Email *

Confirm Email

Phone *

Date of Birth *

🍆 Sexual Wellness Concerns

How often do your symptoms disrupt your sex life? *

Pretty often
Occasionally
Rarely

Which of the following best describes your sexual performance? *

I have difficulty getting hard
I have difficulty staying hard
Both

Are you or your partner unhappy or distressed by how fast you ejaculate? *

How important is improving your sexual performance to you right now? *

Extremely important
Moderately important
Slightly important
Not important at this time

Choose one

🩺 Health Conditions

Are you currently taking any medications? *

Medication name, dosage & frequency

Do you have or have you previously been diagnosed with any of the following? *

Heart attack
Heart failure
High blood pressure
Coronary artery disease
None of the above

Select all that apply

Are you currently taking any medications for blood pressure, heart conditions, or chest pain (such as nitrates or alpha-blockers)? *

Yes
No
Not sure

Have you ever been told by a doctor to avoid sexual activity due to a heart condition? *

Do you have any allergies?

How often do you currently engage in sexual activity or plan to? *

0–1 times per week
2–3 times per week
4+ times per week

Have you used any ED medications in the past (such as Viagra/Cialis)? *

Which medication(s) have you tried and how did it work for you?

💡 Performance Goals

Is there anything else you’d like us to know about your sexual health, concerns, or goals?

of or often

✅ Consent + Submit

Consent & Agreement *

I confirm that the information I provided is accurate and consent to receive care, prescriptions, and follow-up communication from a licensed provider.

I have read and understand the Privacy Policy.

Your personal and health information will be kept confidential and used solely for the purpose of providing medical treatment.

By submitting this form, you agree to our Privacy Policy.

Upload Your Government-Issued Photo ID *

Click or drag a file to this area to upload.

Where to send medication *

Address Line 1

Address Line 2

City

State

Zip Code

Payment Authorization *

[ ] I agree to be charged once my prescription is approved by a provider.

Anything else we should know before processing your prescription?

MYMANOVA

Unlock Your Power with Sexual Wellness!

🧍 Personal Information

🍆 Sexual Wellness Concerns

🩺 Health Conditions

💡 Performance Goals

✅ Consent + Submit

Let’s Talk About Sexual Wellness 💪

Stronger. Sharper. Harder. ✔️ 100% Private and Secure ✔️ Reviewed and Approved by a Board Certified ✔️ Nurse Practitioner ✔️ Discreet Delivery to Your Door ⏱ TAKES LESS THAN 3 MINUTES TO COMPLETE

Stronger. Sharper. Harder.

✔️ 100% Private and Secure
✔️ Reviewed and Approved by a Board Certified
✔️ Nurse Practitioner
✔️ Discreet Delivery to Your Door

⏱ TAKES LESS THAN 3 MINUTES TO COMPLETE