Are you male and over the age of 18?

Is this medication being used by you to treat erectile dysfunction and do you have difficulty achieving or maintaining an erection?

Have you ever been advised by your doctor not to have intercourse for medical reasons?

Have you ever had an allergic reaction to erectile dysfunction medication? Or any other allergies?

How tall are you?

Do you smoke?

Do you drink alcohol?

Are you taking ANY other medication? Or have you just finished a course of medication? This includes over the counter, herbal medication, recreational drugs, and creams, sprays or lotions.

Do you have diabetes, high blood pressure, high cholesterol, a history of stroke, prostate problems, liver or kidney disease or mental health problems?

Do you have any of the following?

• Any heart problems including; heart failure, unstable angina, chest pain, irregular heart beats (arrhythmia e.g. atrial fibrillation or flutter, especially if you are taking medication to treat this e.g. beta blockers or anticoagulant e.g. warfarin), aortic stenosis or uncontrolled blood pressure.
• A heart operation, heart attack or stroke (including a mini stroke) in the last 6 months.
• A history of low blood pressure.
• Difficulty walking at a fast pace for 5 minutes or more due to chest pain, calf pain or shortness of breath.
• Any condition which affects the shape of the penis such as cavernosal fibrosis, angulation or Peyronie’s disease.
• Loss of vision due to NAION (lack of oxygen to the optic nerve) or eye conditions including retinitis pigmentosa, or temporal arteritis.
• Blood conditions including sickle cell anaemia or haemophilia.
• Leukaemia or multiple myeloma.
• Galactose intolerance, lapp lactase deficiency or glucose-galactose malabsorption.
• Active stomach ulcers.

Do you have any of the following?

• I have answered all of the above questions truthfully and confirm that the medication is for my own personal use.
• I have read the patient information leaflet and understand the risks and benefits of taking this medicine.
• I understand I should not take more than the prescribed dose of this medication.
• If I am ordering the Higher Dose I confirm I have tried the Lower Dose.
• I understand that patients being treated for erectile dysfunction are recommended to have their blood pressure checked as well as tests for diabetes, cholesterol or hormone imbalances.
• I understand I should inform my own GP that I am taking this medicine so they can see a full and accurate picture of my health.
• Do not take any NITRATE medicines with erectile dysfunction medication. These are normally prescribed for heart issues. This would be very DANGEROUS, and includes recreational drugs like poppers or cocaine.
• We collect information about your health to make a medical diagnosis and prescribe medicines safely. Under the GDPR this type of data is classed as sensitive and therefore we take further precautions when collecting and processing it. By consenting to this notice, you are giving us permission to process your health data for the purposes of prescribing medicine.
• I agree to be treated by the prescribers and healthcare professionals at Assured Pharmacy for my medical condition.
• I will contact a medical professional if I have any questions or experience any unusual side effects from my treatment.
• I will not take grapefruit juice with this medication as it can increase the risks of side effects.

Your first & last name

Email address

Phone number