0330 383 0309
1.
Do you regularly have difficulty getting or maintaining an erection?
No
Yes
2.
What's your biological gender?
Male
Female
We're sorry, this product cannot be issued for the selected gender.
3.
How old are You?
4.
What is your height?
5.
How much do you weigh?
6.
Do you smoke or drink?
Yes
No
Drinking and smoking can reduce the effects of the drug
7.
Do you have any of the following problems?
Diabetes
High blood pressure
Thyroid problem
Stroke
Angina
Heart attack
Liver disease
Kidney disease
Alcohol and Drugs
Yes
No
8.
Do you have any of the following medical problems or have you been diagnosed with any of the following medical problems in the past 6 months?
Anomaly of the penis
Ischemic retinopathy
Arrhythmias
Blood clotting problems
Sickle cell anemia
Leukemia or Myeloma
Stomach ulcer
No
Yes
We are sorry but we cannot dispense the medication, please visit your local doctor
9.
Are you taking any of the following medications?
Nitrates (glyceryl trinitrate, isosorbide mononitrate, isosorbide dinitrate)
Amyl nitrate (poppers)
Alfuzosin
Doxazosin
Indoramin
Prazosin
Tamsulosin
Terazosin
Nicorandil
Ketoconazole
Itraconazole
No
Yes
We are sorry but we cannot dispense the medication, please visit your local doctor
10.
Are you allergic to any substance, medicine, or food?
No
Yes
11.
What was your last blood pressure measurement?
Low
Normal
High
We cannot dispense the medication if you have low or uncontrollably high blood pressure as it is more likely to cause side effects. We encourage you to speak personally with your doctor about other treatment options.
12.
Have you ever been advised not to do vigorous exercise or sexual activity?
No
Yes
Warning We are sorry, but we cannot dispense the medication, please visit your local doctor
13.
Would you like to give the doctor additional information?
No
Yes
14.
Do you agree not to combine Viagra / Sildenafil, Cialis / Tadalafil, Levitra, Spedra at the same time or use any other ED treatment?
I Agree
We're sorry, but we can't dispense the medication
15.
Would you like us to inform your general practitioner about this order?
No
Yes
16.
Agree to the following points:
I am more than 18 years old
I / we will inform my / your family doctor about this treatment
I certify that all information given is true and I understand that incorrect information can negatively affect me
The drug is for my personal use only
I agree
