First Name *

Last Name *

Email *

Phone *

Do you agree and consent

to the following?

Yes, I agree and consent to the above information.

Let's find you the right treatment.

1.) Do you prefer to plan ahead with (sexual) intercourse, or be spontaneous? *

Plan ahead

Be spontaneous

2.) Have you been diagnosed with erectile dysfunction by a healthcare professional? *

Yes

What is your Weight? (Optional)

What was your last Blood Pressure? (Optional)

4.) What is your age? *

Under 18

18-25

26-49

50 and over

7.) Have you used any of the following medications or recreational drugs? *

Nicorandil, glyceryl trinitrate (GTN) spray, isosorbide mononitrate (ISMN) / dinitrate, amyl nitrate (poppers)

Cimetidine, indoramin, erythromycin / clarithromycin, fluconazole / itraconazole, ketoconazole, miconazole, voriconazole

Citalopram / escitalopram

Rifampicin, indinavir, tipranavir, atazanavir, darunavir, fosamprenavir, saquinavir

Doxazosin / tamsulosin / alfuzosin / terazosin / prazosin

Diltiazem, verapamil, amiodarone

Nilotinib, lapatinib, pazopanib, sunitinib

None of the above

It's really important to tell us about:

Major illnesses
Ongoing medical conditions
Any medication prescribed or over the counter that you take
Allergies to medication
Medical Operations

8.) This information is needed so that our clinicians can ensure the prescription is safe for you to take. *

I have a major illness, ongoing medical condition, operation, allergy to medication or take prescribed or over the counter medication to tell you about.

I do not have a major illness, ongoing medical condition, operation, allergy to medication or take prescribed or over the counter medication to tell you about.