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.I agree to answer questions honestly and fullyYesNo Your ConditionAre you able to control when you ejaculate?*YesNoHow long have you been sexually active?*Less than 6 monthsBetween 6 - 12 monthsBetween 1-5 YearsMore than 5 YearsFor how long has premature ejaculation been a problem?*Just recentlyEver since I started having sexHow often do you find that you prematurely ejaculate?*EverytimeWith a new sexual partnerOther (please specify)Please specifyHow long after penetration does ejaculation usually occur?*Within two minutesMore than two minutesStudies have only been undertaken in men who take less than two minutes to ejaculate. If otherwise suitable, would you still like to try this treatment?*Within two minutesMore than two minutesDo you find that the condition causes you anxiety?*YesNoDo you find that the condition causes relationship problems?*YesNoDo you know what may be causing you to ejaculate prematurely?*YesNoPlease specifyHave you previously tried medication for ejaculating prematurely?*YesNoIf Yes, what medication have you tried?Do you have problems with getting or maintaining an erection before prematurely ejaculating?*YesNoHave you ever received, or are you receiving treatment for erectile dysfunction?*YesNoDid using a treatment for erectile dysfunction also help the issue of ejaculating prematurely?*YesNoWhich medication have you / are you using for erectile dysfuntion?*Your HealthDo you have any history of low blood pressure / fainting / getting dizzy when you stand up?*NoYesPlease provide information*Do you or have you ever suffered from any heart conditions including angina and problems with heart rhythm?*NoYesPlease provide information*Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?*NoYesPlease provide information*Have you ever been disgnosed with a liver or kidney condition?*NoYesPlease provide information*Do you have a bleeding or clotting disorder?*NoYesPlease provide information*Do you have a history of migraines or severe headaches?*NoYesPlease provide information*Have you ever had a serious brain injury, been diagnosed with epilepsy or suffer from seizures?*NoYesPlease provide information*Have you been diagnosed with a stomach / peptic ulcer in the last month?NoYesPlease provide information*Do you have any history of mental health or psychiatric condition such as depression, anxiety, panic attacks, mania, bipolar disorder, schizophrenia or ADHD?NoYesPlease provide information*Do you have any condition where sexual activity is not advised?NoYesPlease provide information*When you ejaculate or when you pass urine, do you have any pain?NoYesPlease provide information*Have you ever had prostate surgery or been diagnosed with any condition of the prostate?NoYesPlease provide information*Do you drink alcohol?NoYesConsentI agree to the site's terms and conditions. I confirm I am over 18 years old. The medicine ordered is for my sole use only. I will read the patient information leaflet supplied with the medicine or obtain it from the website; I will especially take note of the side effects and dosages. I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.*NoYes I Agree Choice of Medication*Priligy 30mg x 3 Tablets - £ 19.50Priligy 30mg x 6 Tablets - £ 37.00Priligy 30mg x 12 Tablets - £ 69.50Priligy 60mg x 3 Tablets - £ 27.99Priligy 60mg x 6 Tablets - £ 49.00Priligy 60mg x 12 Tablets - £ 89.99EMLA cream 25mg x 5g - £20.00EMLA cream 25mg x 30g - £33.00Prescription Charge £ 5.00Total £ 0.00 Name* First Last Email* 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 Phone* This iframe contains the logic required to handle AJAX powered Gravity Forms.