Consultation

Welcome to your private online men's clinic where you will be asked to answer some questions about your health to help us make an informed decision that the medication you are requesting is right for you.

Please select all of the following statements that apply to you

Untitled(Required)

I was assigned male at birth

I am experiencing some form of erectile dysfunction (difficulty getting or maintaining an erection)

None of the above apply to me

Has a healthcare professional ever advised you that you are not fit enough for physical or sexual activity?(Required)

Yes

No

Please provide further information about when you were given this advice and the reason for this advice(Required)

Have you previously used any ED tablets?(Required)

Sildenafil (Viagra)

Tadalafil (Cialis)

Spedra (Avanafil)

Levitra (Vardenafil)

I have not previously used ED treatments

If you have not used any medication to treat your ED before, our prescribers would advise you initially trial a small quantity at a low-dose. This is to check that you do not experience any adverse events or side effects. Most patients start on Sildenafil (Viagra) 50mg.

Are you allergic to any medications?(Required)

Yes

No

Please provide details about your allergy(Required)

Please provide the name of this medication as well as the type of reaction or allergy you hay have had

Are you currently taking any medication?(Required)

This will include prescription medication, over-the-counter and homoeopathic remedies or supplements.

Yes

No

Please provide more information about the medication you take(Required)

Please give the name, strength and instructions of how often you are taking your medication.

Have you been diagnosed with any medical or mental health conditions?(Required)

Yes

No

Please provide details about any previous medical or mental health conditions.(Required)

Please make sure to include details such as diagnosis, symptoms and treatment

Are you taking Nicorandil or any nitrate including GTN spray?(Required)

There can be a fatal interaction between erectile dysfunction medication and this group of medicines.

Yes

No

Please provide more information(Required)

Is there any other information you would like to share with the clinical team so that we can make an informed decision about your health?(Required)

Information such as family medical history or any other factors that may impact your health

Yes

No

Please provide the further information you would like to share with our team(Required)

Information to know about your ED treatment.(Required)

You understand that you should never take a combination of different erectile dysfunction treatments at the same time (Sildenafil and Tadalafil within the same 24 hour period)
You understand that you should seek immediate or emergency medical advice if you have a continuous erection for 4 hours or more.
You confirm and understand that requesting treatment through our service does not guarantee a prescription if the treatment is unsuitable. In this instance, you will be refunded in full and signposted to another point of care. The decision about the treatment is for both patient and prescriber to consider; however, the final decision will always be with the prescriber.

I understand

We highly recommend that you tell your GP of any treatment that you receive privately. Are you happy for us to do this on your behalf?(Required)

Yes

No

Please enter your GP's email address(Required)

Do you agree to the following?(Required)

You are between the ages of 18-65
This treatment is for your use only
You have the capacity to make decisions about your own healthcare
You have understood all of the questions and have answered your consultation truthfully. It is important your answers are true and complete so we can ensure we are prescribing safely.
You will read all of the information within the patient information leaflet (PIL) provided with this medication
I understand the prescriber will take my answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
I accept that prescription medication CANNOT BE REFUNDED once it has left our pharmacy. This is because the returned medication cannot be re-sold to another customer.
If you have not agreed for us to contact your GP on your behalf, you will make them aware that this medication has been prescribed to you so that your patient medication record can be updated
You are aware you will be subject to a soft check to validate your identity
You will contact Mens and inform your GP if you experience any side effects from this treatment or if there are any changes to your health
You have read and understood and agree to abide by our Terms and conditions of website use, terms and conditions of sale, privacy policy, delivery policy, refund policy and cookie policy

I agree to the above information

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