Demo Intake — Erectile Dysfunction (ED)

Stop and get urgent care: Call 911 or go to the emergency department for chest pain or pressure, trouble breathing, fainting, or symptoms of a stroke (face drooping, arm weakness, or speech difficulty).
If you are having any of those symptoms right now, do not continue this form — call 911 now.
Completing this form does not guarantee a prescription. A Texas Clinician, FNP-BC, reviews every case and decides whether treatment is safe and appropriate for you.

Please stop — we will help you get the right care

Questions? Call (940) 257-2002.

If this is an emergency, call 911 now.

Demo complete.

In the real service, this packet goes to a Texas Clinician for review during clinic hours, Mon–Fri 7 AM–5 PM. Exact price shown before you start. The fee covers your Clinician review and is charged once the review is complete, whether or not treatment is approved. Medication, if prescribed, is separate.

Watch for a text and an email from Evolve Health at every step — when your visit is approved and your prescription has been sent to your pharmacy, and if we need anything else from you. Messages never name your condition or medication.

Back to all questionnaires · Back to home

Questions? Call (940) 257-2002.

Step 1 of 12 — Eligibility gates

Are you having any urgent symptom listed above right now? *

No Yes

I confirm each of the following (all must apply): *

I am 18 years of age or older. I am physically located in Texas during this evaluation. I understand this is not emergency care. I understand a Clinician will review my answers and treatment is not guaranteed.

Your date of birth *

Are you physically located in Texas right now? *

Yes No

Step 2 of 12 — About you

Legal first and last name *

Street address *

City *

State *

ZIP code *

Mobile phone *

Email *

How may we contact you about this care? *

Phone call Text message Secure portal message

May we leave a generic voicemail (no medical details)? *

Yes No

Step 3 of 12 — Identity verification

Before a Clinician can prescribe, we verify identity — this protects you and keeps online care safe. Upload a clear photo of your government-issued ID (driver license, state ID, or passport) and a selfie. The name and date of birth on the ID must match this form. Your ID and selfie are stored only in your secure chart.

If your ID cannot be verified, or your selfie does not match the ID portrait, online prescribing cannot proceed on that basis alone: the Clinician may ask for a video visit to verify you visually, and any prescription that follows is pharmacy pickup only.

Photo of the FRONT of your government ID *

Use whichever is easier — Take a photo opens your camera right here, or upload a photo you already have.

Take a photo

Demo only — files are never uploaded.

Upload a photo

Photo of the BACK of your ID — the barcode side *

The barcode on the back must match the front of your ID. This is how we confirm the ID is genuine.

Take a photo

Upload a photo

Selfie *

Look at the camera like a passport photo — no sunglasses or hat.

Take a photo

Upload a photo

The name and date of birth on my ID match the information on this form. * I understand the payment card I use must be in my own name and match my ID. *

Step 5 of 12 — Cardiovascular safety screen

ED treatment and heart health are closely connected, and ED can be an early sign of blood-vessel or heart disease. Answer honestly and completely — a “yes” does not end your care; it helps the Clinician keep you safe, which may mean a video visit or an in-person cardiac evaluation before any treatment is considered.

Have you had chest pain, chest pressure, chest tightness, or chest discomfort — at rest, with physical activity, or during sex? *

No Yes

If yes to F1, describe: when it happens, how long it lasts, what makes it better or worse, and when it last happened

Do you get short of breath, very tired, or unable to keep up with activity that used to be comfortable for you — for example walking, climbing stairs, or physical work? *

No Yes

If yes to F3, describe the activity that brings it on and when you first noticed it

Have you fainted, nearly fainted, or had palpitations or a racing or irregular heartbeat? *

No Yes

If yes, describe — include dates and give approximate dates

Has a clinician ever told you that sexual activity or physical exertion is not safe for your heart, or that you should limit exertion? *

No Yes Unsure

Step 6 of 12 — Nitrate and interacting-medicine safety check

Some medicines must never be combined with ED medicines. This check is a safety essential, and it is one reason your full medicine list in the medicines section matters so much.

Do you take, carry, or use any nitrate medicine — for example nitroglycerin (under the tongue, spray, patch, or ointment), isosorbide mononitrate, or isosorbide dinitrate — regularly, or only when you have chest pain? *

No Yes Unsure

Do you use “poppers” (amyl nitrite or similar recreational inhalants)? *

No Yes

Do you take riociguat (for pulmonary hypertension)? *

No Yes Unsure

Step 8 of 12 — Medicines, allergies, previous ED treatment

List every prescription medicine, over-the-counter medicine, vitamin, supplement, and recreational substance you currently use. Include dose and how often you take it. Include heart and blood pressure medicines, prostate medicines (including alpha blockers such as tamsulosin), antidepressants, and any ED medicine you use now, even if you get it somewhere else. *

Medication allergies or serious reactions (write “None” if none) *

Have you ever used an ED medicine before — for example sildenafil or tadalafil, prescribed, bought online, or shared by someone else? *

No Yes

If yes: which medicine, what dose, how often, and when did you last take it?

If yes: how well did it work, and did you have any side effects (for example headache, flushing, vision or hearing changes, dizziness, or an erection that would not go down)?

Have you used any other ED treatment — for example injections, a urethral suppository, a vacuum device, testosterone, or a supplement marketed for erections or male performance? *

No Yes

If yes, describe — include dates the treatment, results, and any side effects

Have you ever been told NOT to take an ED medicine, or stopped one because a clinician was concerned about your heart or blood pressure? *

No Yes

If yes, describe — include dates

Step 10 of 12 — Measurements

Height *

Weight *

Blood pressure — top number (systolic) *

Blood pressure — bottom number (diastolic) *

Date the blood pressure was taken *

Where was it measured? *

Home cuff Clinic or pharmacy Other

A recent blood pressure reading is needed before an ED medicine can be prescribed. If you do not have a recent reading, most pharmacies will check it free — please get it checked and enter it here. If a reading cannot be provided, or the Clinician needs it confirmed, the Clinician may ask you to confirm it, arrange a video visit, or recommend an in-person visit before deciding.

Who is your primary care clinician, and when was your last visit?

Recent labs we should know about *

Blood sugar / A1c Cholesterol Testosterone None or unsure

Lab dates and results, if known

Step 11 of 12 — How you will receive medication

If the Clinician prescribes, your prescription goes to your own pharmacy for pickup — recommended for a first fill, and the only option if your ID could not be verified. Your insurance can pay for the medication there.

Pharmacy pickup: *

Pharmacy pickup — prescription sent to the pharmacy I name below Mail delivery — Evolve mail plan: one flat total (visit + medication + shipping); mailed in plain packaging, adult signature required.

Mail delivery is available for most medications — not all. Some medications need refrigeration or special handling, and some addresses can't be reached by mail. If mail isn't possible for your medication or your address, we'll tell you before you pay, and your prescription will go to your pharmacy for pickup instead — no extra visit charge.

Pharmacy name and city (for pickup) *

Step 12 of 12 — What happens next + consent

After review, a Clinician may: ask follow-up questions or verify your identity and location; ask you to confirm blood pressure before prescribing; request records or lab tests; schedule a video or in-person evaluation, including an in-person cardiac evaluation when your heart history calls for it; or recommend primary care, cardiology, or emergency evaluation. No medicine is promised.

Payment: your exact price is shown before checkout. Your card is authorized when you submit and The fee covers your Clinician review and is charged once the review is complete, whether or not treatment is approved. Medication, if prescribed, is separate.

Type your full legal name to confirm each statement: *

I attest that I am the person named on this form, that I am 18 years of age or older, and that I am physically located in Texas during this evaluation. The identity and age information I provided is true. The information I provided is complete and accurate to the best of my knowledge. I listed all medicines, supplements, allergies, and relevant health conditions, including any nitrate medicine, poppers, and riociguat. I understand a Clinician may require video, examination, vital signs, records, photographs, or laboratory testing before deciding. I understand submitting this form does not guarantee treatment or a prescription. I understand telehealth has limits and I may be directed to urgent, emergency, specialist, or in-person care, including an in-person cardiac evaluation. I consent to this telehealth evaluation and to the Clinician reviewing my answers, ID, and selfie for identity verification. I will seek emergency care for any emergency warning symptom listed at the top of this form.

Full legal name (acts as your signature) *

Please stop — we will help you get the right care

Demo complete.

Step 1 of 12 — Eligibility gates

Step 2 of 12 — About you

Step 3 of 12 — Identity verification

Step 4 of 12 — Your concern and goals

Step 5 of 12 — Cardiovascular safety screen

Step 6 of 12 — Nitrate and interacting-medicine safety check

Step 7 of 12 — Health history

Step 8 of 12 — Medicines, allergies, previous ED treatment

Step 9 of 12 — Lifestyle and wellbeing

Step 10 of 12 — Measurements

Step 11 of 12 — How you will receive medication

Step 12 of 12 — What happens next + consent