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Ketamine Therapy
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HGH Treatment
ED Treatment
Vitamin Shots
Pain Management
Aesthetic Medicine
SCULPTRA
Radiesse
Butt Augmentation
Penis Fillers
Medical MJ Card
Weight Loss
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Why Choose Us?
Contact
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Home
Our Treatments
Suboxone
Ketamine Therapy
Hormone Therapy
Bioidentical HRT
Low-T Treatment
HGH Treatment
ED Treatment
Vitamin Shots
Pain Management
Aesthetic Medicine
SCULPTRA
Radiesse
Butt Augmentation
Penis Fillers
Medical MJ Card
Weight Loss
Labwork
Why Choose Us?
Contact
FAQ-Videos
Menu
Call
or
Text
Business Discount Order
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1
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4
25%
Select your Business Affiliate
(Required)
Choose an affiliate
DNS
Silas
Hassan
Vitamin Y
Jojo
Are you a New or Returning Patient
(Required)
New
Returning
ED Medications
Sildenafil (Viagra) 50mg (Lasts 3-4 Hours) (30 Tablets)
Tadalafil (Cialis) 10mg (Lasts 24-36 Hours) (30 Tablets)
Tadalafil (Cialis) 5mg (Lasts 24-36 Hours) (30 Tablets)
Tadalafil (Cialis) 5mg (Lasts 24-36 Hours) (90 Tablets)
Hair Loss Medications
Finasteride 1mg (Recommended First For Hair Loss) (30 Tablets)
Finasteride 1mg (Recommended First For Hair Loss) (90 Tablets)
Dutasteride .5mg (Recommended If Tried Finasteride Prior) (30 Tablets)
Dutasteride .5mg (Recommended If Tried Finasteride Prior) (90 Tablets)
Medications
Testosterone (10 Week Supply, Syringes, Consult) (PLEASE NOTE WILL ALSO NEED BLOODWORK INITIAL AS WELL)
Vitamin B12 (10 Week Supply Injectable B12)
Weight Loss Medications
Semaglutide (Ozempic Generic) 5mg Vial-Consult, Semaglutide Vial, and Syringes
Semaglutide (Ozempic Generic) 12.5mg Vial-Consult, Semaglutide Vial, and Syringes
Tirzepatide (Mounjaro Generic) 20mg Vial-Consult, Tirzepatide Vial, and Syringes
Tirzepatide (Mounjaro Generic) 50mg Vial-Consult, Tirzepatide Vial, and Syringes
Phentermine- 1 Month Supply includes Consult and Phentermine Script Sent To Pharmacy Of Choice
Other Services Interested
Medical Marijuana Card
Botox/Filler
Non Surgical Buttlift
Growth Homone Peptides
NAD+ Therapy
What ED medications have you tried?
(Required)
Select all that apply.
None
Viagra (sildenafil)
Cialis (tadalafil)
Levitra (vardenafil)
Staxyn (vardenafil)
Stendra (avanafil)
Bimix/Trimix/Quadmix
In the past 6 months, have you had a confirmed blood pressure reading that was very high or very low?
(Required)
We define “very high” as a Systolic pressure greater than 160 mmHg or a Diastolic pressure greater than 100 mmHg. We define “low” as a Systolic pressure that's less than 95 mmHg, or a Diastolic pressure that's less than 55 mmHg.
Yes, I've had a confirmed very high blood pressure or low blood pressure reading in the past 6 months
No, I have not
High or low blood pressure may increase the risks associated with treatment for erectile dysfunction
(Required)
Popular ED medications, such as Viagra and Cialis, pose certain health risks to those with blood pressure outside the typical range. If you haven't had a blood pressure reading in the past 6 months, we encourage you to get one and to speak with your primary care provider to evaluate any health risks associated with treatment.
I understand and wish to continue
Have you ever been diagnosed with any of these heart conditions?
(Required)
Select all that apply.
None of these
Arrhythmia
Coronary artery disease (narrowing of the heart vessels)
Coronary bypass surgery
Heart attack
Idiopathic Hypertrophic Subaortic Stenosis (aka hypertrophic obstructive cardiomyopathy)
Long QT Syndrome
Any congenital or developmental heart problems
Pulmonary HTN (a rare condition that refers to the blood vessels to the lungs and isn't the same as high blood pressure)
Congestive heart failure or any other heart failure
Do you experience any of these symptoms?
(Required)
Select all that apply.
None of these
Chest pain when climbing stairs or walking
Chest pain during sexual activity
Sudden loss of vision due to loss of blood flow to your eye (aka anterior ischemic optic neuropathy)
Unexplained fainting or dizziness
Cramping or pain in the calves or legs with exercise (aka claudication)
Have you ever been diagnosed with or experienced the following?
(Required)
Select all that apply.
None of these
Organ transplant
Kidney failure, disease, or dialysis
Liver disease
Retinitis Pigmentosa, a genetic condition that typically causes gradual changes to your vision
Diabetes
Told not to have sex for any reason
Sickle Cell Anemia
Stroke
Peyronie’s disease or pain with erections
Foreskin that’s too tight
Active stomach, intestinal, or bowel ulcers or bleeding
Bleeding disorder (causing you to bleed more easily than is normal)
Multiple sclerosis, paralysis, or spinal cord injury
Clotting disorder (you form clots more easily than is normal)
Coconut, coconut oil, Sumadan, and/or cocamidopropyl betaine allergy
Do you currently use or have prescriptions for any of these medications?
(Required)
Select all that apply.
No, I haven’t used these recreational drugs in the last 6 months
Crystal meth (methamphetamines or amphetamines)
Poppers or Rush
Amyl Nitrate or Butyl Nitrate
Cocaine
Molly (MDMA, ecstasy)
Have you used any of these recreational drugs in the last 6 months?
(Required)
PLEASE NOTE: It isn’t safe to take any of these supplements and medications while you’re taking medications that treat erectile dysfunction - it can cause dizziness, fainting and other complications.If you receive a prescription from us, we recommend that you stop taking these supplements.
None of these
Any medicine containing nitrates
Any ALPHA blocker, NOT beta blocker (like Flomax, Cardura, and Minipress)
Nitroglycerin in any form (spray, tablet, patch, or ointment)
Supplements that boost nitric oxide (like L-arginine, L-citrulline, beet root powder/extract/juice concentrate)
Monoket (isosorbide mononitrate), Bidil, or Isordil (isosorbide dinitrate), which are commonly prescribed to prevent chest pain caused by heart disease
Antiretrovirals or any treatment for HIV
Adempas (riociguat)
Just a heads up...
(Required)
ED can be a sign of other undiagnosed medical issues, like heart problems. Smoking, marijuana use, obesity, depression, and low testosterone can all play a role in erectile function (and dysfunction).In addition to seeking ED treatment, we recommend you speak with your primary care provider to rule out other underlying conditions.
Got It
Consent
(Required)
Dutasteride/Finasteride is an oral medication that should be taken once daily with or without meals. Dutasteride/Finasteride takes up to a year or more to exert its full effects in both preventing hair loss and in re-growing hair. During the first six months you may note some thinning of your existing hair.
This may be due to either progression of your hair loss before Dutasteride/Finasteride has had a chance to work or some shedding of miniaturized hair that makes way for the new healthy hair to grow. It is important to be patient during this period. You should continue the medication for at least one year before you and your doctor can assess its benefits.
Side Effects:
Rare (~1-2%), including decreased libido, erectile dysfunction, and reduced ejaculate volume.Some experience persistent erectile dysfunction (PED), affecting ~1% of users.
Side effects typically resolve after stopping the medication.
Other possible side effects:
breast enlargement, depression and anxiety in some users.
Blood Donation & Pregnancy Caution
Users cannot donate blood to avoid exposure to pregnant women.
Women should never handle crushed tablets due to fetal risks.
I consent to treatment
Do You Have Any Of The Following Conditions
(Required)
Please Note You Will NOT Qualify For Phentermine If Any The Below Are Selected
None
Drug Use Disorder
Stroke
Arrhythmias (abnormal heart rhythms)
Congestive heart failure
Hx of Heart Attack
Uncontrolled Hypertension (high blood pressure)
Hyperthyroidism
Do You Have Any Of The Following Conditions
(Required)
Please Note You Will NOT Qualify For Semaglutide or Tirzepatide If Any The Below Are Selected
None
Personal or Family History of Medullary thyroid carcinoma (MTC)
Personal or Family History of Multiple Endocrine Neoplasia type 2 (MEN 2)
Pancreatitis
Is There Any Pertinant Medical History That You'd Like Your Provider To Know?
(Required)
Yes
No
Please Type Anything You'd Like The Provider To Know or Any Questions That You Have
Name
(Required)
First
Last
Phone
(Required)
By giving us your phone number and continuing, you agree that Age Well may send text messages related to your use of our services, including order confirmations, shipment notifications, and messages from your provider.
Date of Birth
(Required)
Month
Day
Year
Gender At Birth
Male
Female
Email
SMS notification
SMS/Text Message notifications with important updates such as prescription expiration reminders, updates from your healthcare provider, shipping and order updates and lab results.
I consent to recieve sms notifications
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
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Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Patient Acknowledgment, Liability Waiver & Truthful Disclosure Agreement
(Required)
By proceeding with treatment through Dr. Islam, Age Well, and any Business Affiliates I acknowledge and agree to the following:Truthful & Accurate Information – I certify that all personal, medical, and health information I have provided is complete, accurate, and truthful to the best of my knowledge. I understand that providing false, misleading, or incomplete information may result in inappropriate treatment recommendations and potential health risks.Understanding of Risks – I acknowledge that all medications, including those prescribed for erectile dysfunction and other conditions, carry potential risks, side effects, and contraindications. I accept full responsibility for any consequences arising from my treatment.No Guarantees – I understand that individual results may vary, and we do not guarantee any specific outcomes from treatment.Medical Advice & Responsibility – I confirm that I have been provided with information regarding my prescribed medication, including its intended use, risks, potential side effects, and proper usage. I understand that I am responsible for following all medical advice and reporting any adverse effects to my provider.Liability Waiver – I voluntarily assume all risks associated with my treatment and release Dr.Islam, Age Well, and any Business Affiliates, its healthcare providers, affiliates, and any associated entities from any claims, liabilities, or damages resulting from my use of prescribed medications, except in cases of gross negligence or willful misconduct.Binding Agreement – By proceeding with my treatment and prescription, I acknowledge that I have read, understood, and agreed to the terms of this waiver, and I accept full responsibility for the accuracy of the information I have provided.
Payment will be due after submiting this form. Once order is placed, please allow the pharmacy up to 7-10 business days for your products to arrive if it is being shipped. If you are not approved by our provider for any of the above you will be given a full refund.
