Your Transformation Journey Begins Now.

THANK YOU FOR YOUR PURCHASE!

Your request for 5mg Daily Tadalafil has been received.

You’re just one step away from unlocking better blood flow, confidence, and TRT results.

WHAT HAPPENS NEXT:

Complete the quick medical intake form below - It only takes 2–3 minutes and ensures Tadalafil is safe and appropriate for your goals.
Our medical provider will review your chart - If approved, your prescription will be shipped to your door immediately.
If you're not approved for treatment, you’ll receive a full refund

First Name

Last Name

Phone *

Email *

Recent Blood Pressure *

Give us your most recent blood pressure reading.

Are you currently taking any prescription medications? *

List any prescription medications you are currently taking

Are you taking Nitrates? *

Yes

No

Are you currently taking alpha blockers? *

Yes

No

Are you currently taking other ED medications (e.g. Viagra, Cialis, Levitra)? *

Yes

No

Do you smoke or use tobacco/nicotine products? *

Yes

No

How often do you consume alcohol? *

Daily

Weekly

Rarely

Never

Do you use recreational drugs? *

Yes

No

Do you exercise regularly? *

Yes

No

Check the boxes if you have had any of the following *

Chest Pain

Shortness of Breath During Physical Activity

Fainting or Dizziness

Allergic reaction to any medications

Additional Comments or Questions

By checking this box, I authorize AZTRT LLC and its affiliated professional entity, Arizona TRT LLC, to charge my card on file for up to $99 if I am approved for treatment based on the information provided in this form. I understand and agree to the following:

Submission of this form constitutes my request for evaluation and authorization for billing if approved.
If my card is on file, I may be charged up to $99 for a one-month supply of daily tadalafil.
If approved, I am authorizing this charge and ongoing monthly charges of $99 for continued refills unless I cancel in writing at least 5 days before the next billing date.
I may cancel ongoing refills by contacting AZTRT LLC directly; cancellation does not apply to any charges already processed.
I understand that this authorization applies regardless of whether I am currently subscribed to another AZTRT service.

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