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Welcome to the secure area, as designated by the https://www, in your browser all information provided during the order process is routed behind a secure “firewall”. The Information is encrypted at your browser and sent via the Hyper Text Transport Protocol to ensure security. Please note: when you place your order on the secure pages the website address changes from the normal http://www protocol to the https://www signifying that all information provided on the page is protected by the Secure Sockets Layer (SSL). (see illustration below)

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Important!

I hereby certify that I am at least eighteen years of age and will carefully read and truthfully answer all of the following questions:

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Address 2: please no commas:	(i.e. apt, suite no.)
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Postal Code Put N/A If Not Relevant:	(required)
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Phone:	(required for overnight courier purposes only)

Billing Information:
Payment Type:	Credit Card Money Order, Western Union, Paypal. When paying by money order, the credit card information is not required. The customer service associates will email you with further instructions concerning payment.
Card Holder:	(required for credit card payment only)
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Expiration Date:	(required for credit card payment only) Example: 10/12
CVV2: (Card Verification Value) 0000000000000000	(required for credit card payment only) For your safety and security, individuals are now required to enter their credit card's verification number (CVV2 code). The verification number is a 3-digit number printed on the back of most credit cards, (the number appears after and to the right of your card number), please refer to the example. If using an American Express card the CVV2 code is a 4-digit number printed on the front of your card, please refer to the example. Please note: By providing the CVV2 code this helps to insure that the credit card is in the possession of the user helping to decrease fraudulent charges.

Billing Address: The next section addresses the actual billing address where the credit card statement is mailed each month. Please enter the exact address of where the credit card statement is sent each month for payment. This address will be verified with the issuing credit card company prior to charging the credit card. The billing address must exactly match the address on file where the credit card statement is mailed each month, or the charges will not be approved. This represents just another security measure taken by The Online Pharmacy UK to prevent fraudulent charges while maintaining our discount Viagra prices.
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Address 1: please no commas:	(required for credit card payment only)
Address 2: please no commas:	(i.e. apt, suite no.) (required for credit card payment only)
Town/City:	(required for credit card payment only)
County/Region:	(optional)
Postal Code Put N/A If Not Relevant:	(required for credit card payment only)

Medical History (Information provided below is protected by patient/doctor privacy laws.
This and all the other information you have entered is encrypted and safe during
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Required Personal Information:
Height:	1in = 2.54cm (required)
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Medical History: Please read the following very carefully. If you have any of the following medical conditions, please follow with an accurate explanation.
Do you or any of your immediate family have a history of the following medical conditions?
Blood disorders e.g. anemia, hemophilia, hemochromatosis, phlebitis, sickle cell anemia, thalassemia, thrombosis, hypercholesterolemia, etc.
Cancer e.g. brain, breast, bladder, colorectal, endometrial, leukemia, lung, lymphoma, multiple myeloma, ovarian, prostate, skin, testicular, etc.
Cardiovascular disease e.g. angina, arrhythmia, atrial fibrillation, claudication, congestive heart failure, valve disorder, heart attacks, high blood pressure, strokes, etc.
Endocrine disorder e.g. diabetes, goiter, hyperthyroidism, hypothyroidism, pheochromocytoma, thyroiditis, etc.
Eye disorders e.g. cataracts, glaucoma, retinal complications, etc.
Gastrointestinal disorder e.g. acid reflux, hiatal hernia, irritable bowel syndrome (Crohn's disease, ulcerative colitis), polyps, rectal bleeding, ulcers, etc.
Genitourinary disorder e.g. benign prostatic hyperplasia, cysts, endometriosis, pelvic inflammatory disease, etc.
Immune disorders e.g. Hashimoto's disease, eczema, HIV, Graves disease, Sjogrens syndrome, sarcoidosis, sclerodoma, etc.
Kidney (urinary tract) disorder e.g. bladder disorders, cystic disease, glomerular disease, nephrotic syndrome, renal failure, urinary tract complications, etc.
Liver disorder e.g. cirrhosis, Gilbert's syndrome, hepatitis, hemochromatosis, Wilson's disease, etc.
Musculoskeletal e.g. arthritis, back/spine complications, fibromyalgia, gout, lyme disease, muscular dystrophy, myasthenia gravis, osteomalacia, osteoporosis, rickets, spinal cord injury, etc.
Neurological disorder e.g. Alzheimer's disease, epilepsy, head injuries, headaches, Huntington's disease, multiple sclerosis, seizure, etc.
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Respiratory disorder e.g. allergic rhinitis, asthma, chronic bronchitis, emphysema, tuberculosis etc.
Other e.g. acne, chemical dependency, menopause, nutritional disorder, obesity, pregnant/nursing, significant trauma, etc.
Do you have a history of any of the medical conditions previously mentioned including Blood disorders, Cancer, Cardiovascular disease, Endocrine disorder, Eye disorders, Gastrointestinal disorder, Genitourinary disorder Immune disorders, Kidney (urinary tract) disorder, Liver disorder Musculoskeletal, Neurological disorder, Psychological disorder, Respiratory disorder, Other conditions (not mentioned)? If yes, please explain. For example, duration of illness, any surgery or treatment (ten year history of hypertension (high blood pressure), Atenolol 50mg one per day - well controlled with medications, Blood pressure 132/84):	Yes No
	0000000

Additional Medical: Please read the following list of medical questions carefully. Be sure to give any explanations if your answer is "yes" to any of the following.
Currently, are you taking any medications (this includes over-the-counter or nonprescription medication, herbal supplements, sports supplements, etc.) If yes, please explain(medication, supplement including dosage):	Yes No
Are you allergic to any medications, supplements or food products? If yes, please explain (medication, supplement, and the allergic reaction experienced):	Yes No
Do you consume more than two servings of alcohol per day or use tobacco products? If yes, please quantify type of product and usage:	Yes No
Do you currently follow a routine exercise program? If yes, please quantify type and amount of exercise:	Yes No
	0000000

Viagra Specific Questions: The On Line Pharmacy UK doctors and staff are dedicated to providing you with the necessary information and resources to make intelligent decisions concerning your health. Although the general use of Viagra is very safe, you should realize that there are certain medical conditions in which Viagra is not appropriate. Prior to buying Viagra online, please review the Viagra prescribing information. If you have a history of any of the listed medical conditions and/or you are taking any of the medication listed in the Viagra Precaution and Drug Interactions sections, please visit your local doctor. This does not mean that Viagra is not appropriate for your condition, however, our doctors strongly believe that it would be in your best health interest to obtain a Viagra prescription via a traditional office visit.
Do you have a history of any cardiovascular complications e.g. heart attack, congestive heart failure, unstable angina (chest pain), arrhythmia (an abnormal heartbeat rhythm) uncontrolled hypertension or hypotension, history of postural hypotension, stroke, transient ischemic attacks (TIAs), etc? If yes please explain:	Yes No
Do you have a history of any blood disorders e.g. sickle cell anemia, thalassemia, bleeding disorders, etc? If yes please explain:	Yes No
Viagra® is contraindicated in individuals who are currently taking or have a history of taking any medication which contain nitrates. Combining Viagra with nitrates can result in a dangerously low blood pressure that can result in a heart attack, stroke or even death. Are you currently taking any medications that contains nitrates or any medications that have nitro or isosorbide in their names? If yes please explain.	Yes No
Do you have an abnormal curvature of the penis (Peyronie's disease) or a history of priapism (painful/prolonged erection)? If yes please explain.	Yes No
Viagra® is prescribed for the treatment of erectile dysfunction. Our physicians will only prescribe Viagra for individuals that have some difficulty in this area. Do you have difficulties either achieving and/or maintaining an erection sufficient for sexual intercourse? If yes please explain.	Yes No
Have you ever been evaluated and subsequently treated for erectile dysfunction (injection therapy, vacuum pump, penile implant, etc.)? If yes please explain.	Yes No
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To avoid delays in processing and/or delivery time, please be sure that all of the above questions that are marked as (required) have been properly filled out. Also check to see if you properly selected the quantity you wish to receive.

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