Your health and safety are our top priorities. To ensure we provide you with the most effective and appropriate treatment, it is crucial that you provide accurate and complete information about your health during our online consultation process. Accurate information helps us understand your condition better, assess any potential risks, and recommend the best possible medication for your needs. Providing false or incomplete information can lead to inappropriate treatment, potential health risks, and delays in receiving the care you need. Thank you for your cooperation and trust in our services.

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Male
Female
Transmale (Born a female)
Transfemale (Born a male)

Please select either Metric or Imperial measurements :

Metric (Centimetre and Kilograms)
Imperial (Feet and Pounds)


Yes
No
Occasionally

If yes, please specify.

Select all that apply.

Cardiovascular disorders (including angina, heart failure, stroke, or myocardial infarction)
Hypotension (<90/50mmHg) or hypertension
Bleeding disorders or active peptic ulceration
Severe hepatic impairment
Severe renal impairment requiring dialysis
History of non-arteritic anterior ischaemic optic neuropathy (NAION)
Hereditary degenerative retinal disorders (e.g., retinitis pigmentosa)
Diabetes mellitus with vascular involvement
History of anatomical penile deformity (e.g., Peyronie’s disease)
Conditions predisposing to priapism (e.g., sickle cell anaemia, multiple myeloma, leukaemia)
Not applicable

If yes, please list them.

Select all that apply.
Nitrates (e.g., glyceryl trinitrate, isosorbide mononitrate)
Nicorandil
HIV protease inhibitors (e.g., ritonavir, indinavir)
Ketoconazole or itraconazole
Antiarrhythmics (Class 1A - quinidine, procainamide; Class III - amiodarone, sotalol)
CYP3A4 inducers (e.g., rifampicin, phenobarbital, phenytoin, carbamazepine)
Alpha-1 blockers
5-alpha reductase inhibitors
Grapefruit juice (regular consumption)
Not applicable

If yes, please provide further information.



Accurately describing your condition during our online consultation is essential for ensuring you receive the best possible care. Detailed and truthful information about your symptoms, their frequency, and their severity allows our healthcare professionals to make informed decisions about your treatment. Incomplete or incorrect descriptions can result in inappropriate medication, potential health risks, and delays in your care. Your honesty and thoroughness help us provide you with the most effective and safe treatment options. Thank you for your cooperation and trust in our services.

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If yes, which medication(s) have you used?






Please take the time to carefully read the Agreement and Consent statements during our online consultation process. Understanding these statements is essential for your safety and for ensuring that you are fully informed about the treatment you will receive. The Agreement and Consent sections outline important information about the risks, benefits, and responsibilities associated with your medication. By reading and agreeing to these terms, you help us ensure that you are aware of and comfortable with the treatment plan. Your informed consent is crucial for providing you with the best possible care. Thank you for your cooperation and trust in our services.

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  • I confirm that the information I have provided in this form is accurate to the best of my knowledge.
  • I understand that providing false or incomplete information may affect the safety of my treatment.

  • I understand that erectile dysfunction medication is not suitable for everyone and should only be taken under appropriate medical supervision.
  • I confirm that I do not have any medical conditions that would prevent me from safely taking this medication.
  • I understand that this medication may have side effects, including headache, flushing, nasal congestion, dizziness, and potential vision changes.

  • I agree to report any severe or prolonged side effects to my GP or pharmacist.
  • I understand that I must seek medical attention if I experience chest pain, sudden vision loss, or an erection lasting more than 4 hours (priapism).
  • I understand that erectile dysfunction medication should not be combined with nitrates or certain other medications, as this could cause a dangerous drop in blood pressure.

  • I am requesting medication for the treatment of erectile dysfunction.
  • I have had the opportunity to ask questions and understand the risks and benefits.
  • I accept full responsibility for taking this medication as advised.