Erectile Dysfunction

Do you currently suffer with difficulty getting or maintaining an erection?

Has a healthcare professional or any body else ever advised that you are not fit enough for sexual activity?

Have you previously used any tablets for erectile dysfunction?

If you have previously used erectile dysfunction treatment- did you ever experience any side effects?

Have you ever experienced low blood pressure (BP below 90/50) or ever fainted or collapsed due to your blood pressure?

Have you ever previously been diagnosed with any heart conditions or had any major health incidents involving the heart? (e.g. Heart attack or stroke)

Have you ever been diagnosed with any other medical conditions? (this includes any liver or kidney issues)

Do you suffer with any allergies?

Do you currently take any medication, this includes all prescription medications, any herbal medications or over the counter purchased medications? (this also includes any recreational drugs including poppers or cocaine)

Is there any other information you would like to share with our prescribing team?

We strongly recommend that you inform your GP of any treatment you receive. Would you like us to do this on your behalf?

Do you agree to the following?
- I am between the ages of 18 and 65

- This treatment is for my use only

- I have the capacity to make decisions about my own healthcare

- I have understood all the questions and have answered this consultation truthfully and completely

- I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health

- I will read the patient information leaflet supplied with this medication

- I will contact we prescribe and inform my GP if I experience any side effects from this treatment or if there are any changes to my health

- I have read, understood and agree with our Terms and Conditions