Erectile Dysfunction Consultation

Personal Information

Please provide your details accurately

Name *

First

Last

Date of birth? *

Phone number? *

Address? *

Email? *

Please specify from the following medication that you would like to get prescription for? *

Viagra (Sildenafil) Cialis (Tadalafil) Levitra (Vardenafil) Spedra (Avanafil) Others

If Others, Please Specify:

Please specify the dose of medication from the list below, if you don't know, please select 'Don't Know' *

Are you allergic to any medication? *

NO YES, I HAVE ALLERGIES

If YES, please specify:

Have you ever used this ED treatment previously? *

NO YES

Please specify your age? *

Have you ever been prescribed ED treatment before? *

NO YES

When did you get your blood pressure checked last time? *

Please specify below if you remember the last blood pressure reading? (eg: 120/80 mmHg)

Do you have any past medical history or any past surgical history that you want to mention to our doctor? *

NO YES

If YES, please specify:

Are you on any regular medications? If yes please specify below.

Psychological & Lifestyle

This information helps the GP assess your overall health

Have you ever been diagnosed with psychological or psychiatric issues (e.g. anxiety, panic attacks, depression, mania, bipolar disorder or schizophrenia)? *

NO YES

If YES, please specify:

Is your ED impacting your relationship? *

NO YES NOT CURRENTLY IN A RELATIONSHIP

Do you exercise regularly?

NO YES, I DO

If YES, please specify:

Do you smoke cigarettes? *

Do you drink alcohol? Please specify *

Are you currently taking any prescription, non-prescription or illegal drug or herbal medication? And have you recently taken any medication in the last two weeks? Please specify. *

NO YES, I AM

If YES, please specify:

Pharmacy & Confirmation

Almost done - confirm your details

Please specify the name of Preferred pharmacy where you want to get your prescription/medications? *

Declaration

I understand the above mentioned questions and I have answered them truthfully and to the best of my knowledge.

I CONFIRM

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Review and complete your consultation

Order Summary

ED Consultation

GP Review + Prescription

€5.00

Total €5.00

Your Details

A qualified GP will review your consultation and contact you within 24 hours. If the prescription is not appropriate for you, a full refund will be issued.

Erectile Dysfunction Consultation

Personal Information

ED Symptom History

Psychological & Lifestyle

Pharmacy & Confirmation

Declaration

Checkout

Order Summary

Your Details