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Please fill in the erectile dysfunction consultation below

Legal first name

Legal surname

Your Date of birth?

Your Email address?

Your mobile number?

Your Home address?

Your Delivery address?

Your GP surgery name and address

NHS number (optional)

Is this treatment for you, and are you a man aged between 18 and 75?

Yes

This service is only available to adult patients requesting treatment for themselves.

Which option best describes the difficulty you are experiencing?

I cannot achieve an erection firm enough for sexual activity

I can achieve an erection but cannot maintain it

I experience both of these problems

None of these options describe my symptoms

How long have you experienced erection difficulties?

Less than three months

Between three and six months

More than six months

Have you used any erectile dysfunction treatment before?

Examples include sildenafil, tadalafil, avanafil, Viagra or Cialis.

Yes

Please provide the treatment name, strength if known, whether it worked and whether you experienced any side effects.

Examples include sildenafil, tadalafil, avanafil, Viagra or Cialis.

Do you currently use, or are you likely to require, any of the following medicines or substances?

Nitrate medicines for chest pain, including GTN spray, glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate

Nicorandil

Riociguat

Recreational poppers, including amyl nitrite

Alpha-blockers, including tamsulosin, alfuzosin, doxazosin or terazosin

ketoconazole or itraconazole

Erythromycin or clarithromycin

Cimetidine

Other medicines for erectile dysfunction. Examples includes sildenafil, tadalafil, vardenafil, avanafil

None of these

I am not sure

Do you currently have, or have you previously experienced, any of the following?

Angina, chest pain during exercise or chest pain during sexual activity

Advice from a healthcare professional that sexual activity may be unsafe for you

A heart attack or stroke during the last six months

Serious heart disease, significant heart failure or a serious abnormal heart rhythm

Very low blood pressure or uncontrolled high blood pressure

Sudden loss of vision in one eye due to reduced blood flow, sometimes called NAION

An inherited retinal condition, including retinitis pigmentosa

Severe liver disease

Severe kidney disease or dialysis

None of these

I am not sure

Have any of the following ever applied to you?

Sickle cell disease

Leukaemia

Multiple myeloma

Peyronie’s disease

Significant curvature, injury or abnormality of the penis

Severe genital or pelvic pain

An erection lasting four hours or longer

None of these

I am not sure

Have you ever had an allergic reaction to sildenafil, tadalafil, avanafil or another medicine?

Yes

I am not sure

Please list all medicines and health products you currently use.

Include prescription medicines, pharmacy or shop-bought medicines, inhalers, creams, vitamins, supplements, herbal products, recreational drugs and other erectile dysfunction treatments.

Please confirm each statement below.

I confirm that I am requesting treatment for myself.
I confirm that the information I have provided is accurate and complete.
I understand that withholding medical information or details of my medicines could make treatment unsafe.
I understand that completing this consultation does not guarantee that treatment will be prescribed.
I understand that erectile dysfunction medicines must not be combined with nitrate medicines, riociguat or recreational poppers.
I understand that I must seek urgent medical assistance if I develop chest pain, sudden loss of vision or hearing, or an erection lasting four hours or longer.
I understand that the prescriber or pharmacy team may contact me for more information.
I understand that the prescriber may recommend that I speak to my GP or another healthcare professional.
I confirm that I have read the eMeds privacy notice and consent to my health information being used to provide this service.

Do you agree to all the statements above?

Yes

You cannot proceed this treatment

Based on the details you provided, we cannot safely prescribe weight loss medication for you. We recommend asking your GP for advice about losing weight.

Annie



The pharmacist was amazing. He helped answer all my questions regarding weight loss injections. He took my blood pressure made sure everything was perfect. Answered questions I need to know definitely return felt confident in his knowledge

John Williamson



The consultant was good and had the information I was looking for and I am going to enjoy trying this treatment to see if it helps me to lose weight thanks.

Lynda



Reassuring start to my weight loss journey. Given appointment quickly, and reassuring that a couple of things were checked with GP. Everything explained clearly, and my questions answered. I was assured that I should be in touch with pharmacist if there were any problems.

Danny Rawlings



Very professional, helpful, and reassuring Would recommend to anybody looking to purchase weight loss medication.

Anthony



My weight loss journey The pharmacist was very helpful and went into detail regarding the weight loss treatment, explaining any possible side effects that may happen.

Mr Keith Allan



Weigh loss management we had a lot of questions,and answers were provided, made us feel at ease and ensured that we were happy to go a head with the weight loss plan, We felt that any other issues we have we can contact them any time.

FeeP



A thoroughly positive experience My weight loss consultation was a thoroughly positive experience. From the very first phone conversation to the end of the introductory consultation, Jane gave me all the relevant information and really listened to my questions and concerns.

Charles Terry



Sai was very understanding of my situation and reasons for taking advantage of the weight loss programme. He explained clearly what was involved and gave additional support in terms of the diet I should try to follow.

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07344 110940
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