Premature Ejaculation Consultation

Personal Information

Please provide your details accurately

Name *

First

Last

Date of birth? *

DD

MM

YYYY

Phone Number? *

Address? *

Email? *

Have you ever taken any medication for your premature ejaculation before? *

Yes No

If Yes, please specify:

Which of the following medication would you like to get prescription for premature ejaculation? *

EMLA PRILIGY Other

If other, please specify:

When did you notice that you are suffering from Premature ejaculation? *

I noticed it when I started having sex This is only a recent development Other

If other, please specify:

How often do you experience PE? *

Everytime I have sexual intercourse Only when I have sexual intercourse with a new partner Other

If other, please specify:

What stage do you get ejaculation?

Do you experience PE when you masturbate?

Do you suffer from Erection problem as well along with Premature ejaculation? *

No Yes

Have you been treated for Erectile dysfunction? *

No Yes

If Yes, please specify:

Final Details

Almost done! Please complete the following

Please specify your gender? *

Male Female

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

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

Checkout

Review your details and complete payment

Consultation Summary

PE Consultation Fee

GP Review + Prescription

€25.00

Your payment is processed securely via Stripe. We never store your card details.

Premature Ejaculation Consultation

Personal Information

Medical History

Final Details

Checkout

Consultation Summary

PE Consultation Fee