1 IMPORTANT!2 Your Condition & Your Health3 Product Choice4 Details & PaymentBefore you start, it is important that you read this:Welcome to our online clinic. This assessment forms the basis of today's consultation. We need you to be honest with your answers so our doctor can prescribe medication safely and give you the right advice. If you forget to tell us something or give inaccurate information, we may prescribe a drug that can harm rather than help you. It's important that you tell us about any medication you are already taking when we ask for this.PLEASE READ THIS STATEMENT, AND CHECK THE BOX IF YOU WISH TO PROCEED*I DO TAKE NITRATE MEDICATIONI ACKNOWLEDGE THE ABOVE NOTIFICAITON, AND CAN CONFIRM THAT I AM NOT ON ANY NITRATE MEDICATION. I ALSO COMMIT TO ANSWERING QUESTIONS FULLY AND HONESTLY Did your erectile dysfunction appear over a period of time, or suddenly?*SuddenlyOver a period of timeDo you ever get an erection?*NoYesDo you know the cause of your ED?* No Age Nerves / Stress / Tiredness Depression Medical Condition / Medication Unhealthy lifestyle (i.e smoking / drinking) OtherHave you previously been treated for ED?*NoYesWhich medication were you prescribed?*CialisLevitraSildenafil / ViagraOtherWould you like to continue with the same treatment?*YesNoHave you ever had prostate surgery or been diagnosed with any conditions of the prostate?*NoYesDo you have Peyronies disease?*NoYesDo you have any other deformity of your penis?*NoYesAre you circumcised?*NoYesAre you taking any prescription medicines?*NoYesPrescription Medicines*Do you suffer any allergies?*NoYesAllergies*Do you suffer from any conditions in which sexual activity is not advised?*NoYesDo you suffer from angina, aortic stenosis, hypertrophic obstructive cardiomyopathy, uncontrolled blood pressure (over 160/90), arrhythmia, or severe heart disease?*NoYesGive Details*In the last six months have you had a heart operation, stroke or heart attack?*NoYesDo you have a history of low blood pressure, fainting or, after lying down, do you get dizzy when you stand up?*NoYesHave you ever been diagnosed with diabetes or abnormal blood sugar levels?*NoYesHave you ever suffered from loss of vision in one eye from non-arteritic anterior ischaemic optic neuropathy?*NoYesHave you suffered from any hereditary degenerative retinal disorders such as retinitis pigmentosa?*NoYesHave you ever been diagnosed with a liver condition?*NoYesHave you ever suffered from kidney stones or another liver condition?*NoYesIn the last month, have you been diagnosed with a stomach or duodenal (peptic) ulcer?*NoYesDo you have a blood clotting disorder, sickle cell disease, multiple myeloma or leukaemia?*NoYesDo you have galactose intolerance, glucose-galactose malabsorption, or Lapp lactose deficiency?*NoYes Choice of Medication*Cialis 2.5mg x 28 - £ 68.95Cialis 2.5mg x 56 - £ 137.95Cialis 5mg x 28 - £ 71.95Cialis 5mg x 56 - £ 142.50Cialis 10mg x 4 - £ 37.95Cialis 10mg x 8 - 68.65Cialis 10mg x 16 - 132.00Cialis 20mg x 4 - £ 38.95Cialis 20mg x 8 - £ 71.95Cialis 20mg x 16 - £ 137.95Cialis 20mg x 24 - £ 197.95Levitra 5mg x 4 - £23.45Levitra 5mg x 8 - £45.65Levitra 10mg x 4 - £29.65Levitra 10mg x 8 - £58.35Levitra 10mg x 16 - £116.95Levitra 10mg x 24 - £165.95Levitra 20mg x 4 - £30.95Levitra 20mg x 8 - £60.95Levitra 20mg x 16 - £122.95Levitra 20mg x 24 - £184.55Sildenafil 25mg x 4 - £7.85Sildenafil 25mg x 8 - £13.95Sildenafil 25mg x 16 - £23.95Sildenafil 50mg x 4 -£8.45Sildenafil 50mg x 8 - £15.45Sildenafil 50mg x 16 - £25.95Sildenafil 100mg x 4 - £8.99Sildenafil 100mg x 8 - £16.99Sildenafil 100mg x 16 - £28.00Viagra 25mg x 4 - £24.25Viagra 25mg x 8 - £44.25Viagra 25mg x 16 - £82.00Viagra 50mg x 4 - £29.25Viagra 50mg x 8 - £59.25Viagra 50mg x 16 - £112.50Viagra 100mg x 4 - £33.75Viagra 100mg x 8 - £64.25Viagra 100mg x 16 - £124.5Trial Pack - 4x(Sildenafil 50mg, Cialis 10mg and Levitra 10mg) - £74.99Prescription Charge £ 5.00Total £ 0.00 Name* First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Phone* This iframe contains the logic required to handle AJAX powered Gravity Forms.