Please answer the following questions about yourself (the person who will take this medicine). If you get stuck or need any help, use our CHAT button below or give us a Call on 01639 502860

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Please select your option

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

  • Cardiovascular (heart) or have had a stroke
  • Liver or Kidney problems
  • Diabetes
  • Thyroid
  • Immune System
If yes please provide more details

  • OTC (bought medicines)
  • Supplements
  • Herbal Medicines
  • Recreational Drugs



 

If yes please provide more details


If Yes please provide more details on how many units per week and usually when consumed

If yes please provide more details

Please provide more information on the type if you do

e.g. I live with 2 people and a cat, am a painter and decorator

If yes please provide more details

If yes please provide more details




Please answer the following questions to help us understand more about your symptoms and health

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Please add if you have ever experienced any side-effects.

Please add when your last BP reading was

Have you ever fainted or collapsed due to low blood pressure?


  • Heart disease, heart attack, angina or any other heart problems
  • Stroke, mini-stroke (transient ischaemic attack)
  • Sight loss due to poor circulation, inherited eye disease – retinitis pigmentosa or any other eye conditions
  • severe kidney or liver disease
  • deformity of the penis (e.g. Peryonie’s Disease), painful erections or priapism
  • Sickle cell disease / leukaemia / multiple myeloma
  • bleeding conditions (e.g. haemophilia), stomach ulcers (e.g. gastric/peptic ulcer)
  • Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption
  • Any condition which may require immediate hospitalisation


I understand that I should consult my doctor within 6 months of starting treatment for a clinical review.

  • a prolonged erection of more than 4 hours
  • any sudden visual impairment,



Please confirm your agreement to our prescribing partnership

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  • You will read the patient information leaflet supplied with your medication. The treatment is solely for your use (or the person you have completed this for and with their consent). You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

We advise you share this treatment with your doctor so they can update your medical records.