Patient Reorder Form Name* First Last Date of Birth* MM slash DD slash YYYY Phone*Email* Sildenafil - 150mg Troche Rapid Desolving Tablet (RDT) QuantityVardenefil - 75mg Troche Rapid Desolving Tablet (RDT) QuantityTadalafil - 6.25mg / 75mg 6.25mg Troche 6.25mg RDT 75mg Troche 75mg RDT QuantityTrimix - Injectable Medication Trimix Quantity
