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Age Well Dr
  • 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
  • Guides
  • Videos
Age Well Dr
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Business Discount Order

Step 1 of 4

25%
Are you a New or Returning Patient(Required)
ED Medications
Hair Loss Medications
Medications
Weight Loss Medications
Other Services Interested
What ED medications have you tried?(Required)
Select all that apply.
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.
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.
Have you ever been diagnosed with any of these heart conditions?(Required)
Select all that apply.
Do you experience any of these symptoms?(Required)
Select all that apply.
Have you ever been diagnosed with or experienced the following?(Required)
Select all that apply.
Do you currently use or have prescriptions for any of these medications?(Required)
Select all that apply.
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.
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.
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.
Do You Have Any Of The Following Conditions(Required)
Please Note You Will NOT Qualify For Phentermine If Any The Below Are Selected
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
Is There Any Pertinant Medical History That You'd Like Your Provider To Know?(Required)
Name(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)
Gender At Birth
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.
Address
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.
Clear Signature

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.

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