1 IMPORTANT!2 Your Condition & Your Health3 Product Choice4 Details & PaymentWARNING!Welcome to our online clinic. This questionnaire forms the basis of today's consultation. Just as with your GP, we need you to be honest with your answers so we can prescribe medication safely. There is a fatal reaction between ED tablets and nitrate medication, including GTN spray. Do not buy ED medication from us if you have a GTN spray, gel or cream or take any nitrate tablets (usually prescribed for heart conditions). You need to see your GP to discuss alternative options.Welcome to our online clinic. This questionnaire forms the basis of today's consultation. Just as with your GP, we need you to be honest with your answers so we can prescribe medication safely.There is a fatal reaction between ED tablets and nitrate medication, including GTN spray.Do not buy ED medication from us if you have a GTN spray, gel or cream or take any nitrate tablets (usually prescribed for heart conditions). You need to see your GP to discuss alternative options.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 HONESTLYDid 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?*NoYesTreatment Preferred*CialisLevitraSildenafilViagraViagra Strength*25mg50mg100mgSildenafil Strength*25mg50mg100mgCialis Strength*2.5mg5mg10mg20mgLevitra Strength*51020Viagra 100mg Quantity*4816Viagra 50mg Quantity*4816Viagra 25mg Quantity*4816Sildenafil 50mg Quantity*4816Sildenafil 25mg Quantity*4816Sildenafil 100mg Quantity*4816Cialis 5mg Quantity*2856Cialis 2.5mg Quantity*2856Cialis 10mg Quantity*4816Cialis 20mg Quantity*481624Levitra 20mg Quantity*481624Levitra 10mg Quantity*481624Levita Disp x 4Levita Disp x 4Levitra 5mg Quantity*48Prescription 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. 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