To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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Born male
Born female




Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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This may be to any medicines or other substances e.g. peanuts/soya)


Either prescribed or over the counter, including herbal remedies, supplements, or recreational drugs.


  • Heart disease
  • Heart attack
  • Angina (chest pain during exertion)
  • Stroke
  • Mini-stroke (transient ischaemic attack)
  • Sight loss due to poor circulation
  • Inherited eye disease – retinitis pigmentosa
  • Kidney or liver disease
  • Deformity of the penis (e.g. Peryonie's disease)
  • Painful erections
  • Sickle cell disease
  • Leukaemia
  • Multiple myeloma
  • Bleeding conditions (e.g. haemophilia)
  • Stomach ulcers (e.g. gastric/peptic ulcer)


Normal blood pressure around is 120/80 mmHg

Yes
No
Not sure




Symptoms can include:

  • continuous low mood
  • feeling hopeless
  • low self-esteem
  • lack of energy
  • lack of sex drive



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  • This treatment is solely for your own use
  • You will read the manufacturer’s patient information leaflet and stop and report and adverse effects immediately to the relevant healthcare professional
  • You understand that you should stop your erectile dysfunction medication if unexpected side effects occur
  • Y0u confirm that you have answered all the above questions accurately and truthfully. You understand our team take your answers in good faith and base their decisions accordingly, and that incorrect information can be hazardous to your health.

Please ensure the medication is stored safely out of reach of young children or pets to prevent accidental ingestion.


Please state your registered GP if you haven't done so already when signing up