Patient Reorder Form Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Phone*Email* Sildenafil - 150mgTrocheRapid Desolving Tablet (RDT)QuantityVardenefil - 75mgTrocheRapid Desolving Tablet (RDT)QuantityTadalafil - 6.25mg / 75mg6.25mg Troche6.25mg RDT75mg Troche75mg RDTQuantityTrimix - Injectable MedicationTrimixQuantity
