Question 1 of 11 0% 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 confirm the following is true and accurate before continuing with this health consultation? You were assigned male at birth You often ejaculate within 2 minutes of sexual penetration This causes you personal distress of problems in your sexual relationship(s) Untitled(Required) I confirm Has your GP or specialist previously prescribed this medication for you?(Required) Yes No What dose were you prescribed and did you reach the desired outcome?(Required) 30mg tablets and they worked 30mg tablets and they did not work 60mg tablets and they worked 60mg tablets and they did not work If you have not been prescribed this medicine by a GP or clinical specialist, please provide more details as to why you are placing an order online(Required) Do you suffer from any of the following issues?(Required) Pain whilst ejaculation Problems getting or maintaining an erection Difficulty or pain passing urine Feeling faint when standing up after laying down None of the above Please provide more information(Required) 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 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 Premature Ejaculation treatment.(Required)You understand that you should not take any medication to treat erectile dysfunction on the same day as taking premature ejaculation medication.You understand that when taking premature ejaculation treatment you should be started on the lower dose and only increased to the highest strength if required.You understand that you should take this medication 1-3 hours before you need it and not more than once in a 24 hour period.You understand this treatment can lower your blood pressure and cause dizziness in some men.You understand that consuming alcohol with this medication, can increase the likelihood of low blood pressure and can also enhance the effects of the alcoholYou understand that you should stop taking this medication and seek immediate or emergency medical help if you experience any of the following: feeling faint or lightheaded on standing up, fits (seizures), change in your mood, thoughts of suicide or harming yourself.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 18-65This treatment is for your use onlyYou have the capacity to make decisions about your own healthcareYou 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 medicationI 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 healthI 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 updatedYou are aware you will be subject to a soft check to validate your identityYou will contact Mens and inform your GP if you experience any side effects from this treatment or if there are any changes to your healthYou 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 informationconsultationID
