Welcome to our online Registration

Here you'll tell us about your health, medical history, symptoms, and tell us if you have any medication preferences.


done  Pay a low flat rate for your visit with a medical provider. Then pay the lowest amount possible for your medications by selecting a pharmacy near you to pick up locally. If you prefer we can have an independent pharmacy discreetely mail your medications directly to you.

security  Your information is secure and will be reviewed by a US Licensed Medical Provider. Then you will have a video conference call with a provider that can legally prescribe you medications as indicated and necessary.

Getting Started
Email Address
First Name
Last Name
Phone Number
Basic Info
This information will help to determine if you're eligible for treatment.
Please enter your home address to match the zipcode you previously entered.
Street Address
*Only states which we are licensed are available in the dropdown.
Over the past month have you experienced symptoms of depression (sad, lack of interest in doing things you enjoy, sleep difficulties) and/or anxiety (feeling nervous or worrying to much about things) that are independent from feeling depressed and/or anxious regarding your ED?
Please answer the following series of questions:
How many times do you anticipate using the medication for sexual activity, if prescribed?
Do you have a drug preference?
Some pharmacies accept discount coupons such as GoodRX and others do not. Check with your pharmacy of choice for their exact pricing. All prescription medication pricing is determined by each pharmacy and EXPHS has zero control over the prices they charge.
What is the number of months supply that you are requesting?
You need to know what your average blood pressure (BP) runs in order to be prescribed an ED prescription. Select from the categories below to indicate what your average BP has been within the past 6 months:
Is your desire to have sex (libido)
Do you wish to receive any information or promotions from Express Men's Health?
Current/Past Medical History - Check all that apply:
Past Surgical History - Check all that apply:
Social History - Check all that apply:
ED can be a sign of disease processes such as Diabetes, Hypertension, Coronary Artery Disease, Peripheral Vascular Disease, and other conditions. ED symptoms can also present prior to these disease processes fully developing. Do have any of the following symptoms:
Select if you have any of the following contraindications to taking prescription ED medicines. Realize that taking prescription ED medications can KILL IF you take them despite having contraindications to taking them. Be truthful in your response.
Cautions: Select if you currently have any of the following cautions to taking ED medicines:
Are you allergic to any of the following:
Please list any other allergies to medications:
Please list any medications you are currently taking:
Is there anything else that you feel that we should know about you, your health, and/or any medicines (prescription and non-prescription, legal and illegal/illicit) that you take?
ED can be brought on by poor lifestyle habits/choices. ED can also occur even if you do everything you can correctly regarding your lifestyle habits/choices. We advise that you get at least 3 thirty-minute episodes of cardiovascular exercise weekly (this statement assumes that your primary care provider has cleared you for such exercise). We also advise that you maintain a healthy weight, and that you eat a well-balanced diet. Additionally, we advise that you have an annual physical exam by your PCP. We advise that you closely monitor your blood pressure and that you work with your PCP to ensure that your blood pressure is within normal limits. We advise that you not smoke tobacco, that you should not drink more than 2 servings of alcohol daily, and that you get adequate sleep. I acknowledge these recommendations and will work to follow them.

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Submit payment for the visit:
Card Holders Name
Credit Card Number
Expiration Month
Expiration Year
CVV Code

Thank You

You will be contacted shortly to begin your visit.