Date Format: MM slash DD slash YYYY
Has your doctor advised that you are not fit enough for any physical, or sexual activity.
Do you have difficulty with light/moderate excercise, such as a brisk walk for 5 mins.
Low blood pressure (below 90/50) or uncontrolled high blood pressure (150/90)
unstable angina, irregular heart beat or palpitations
Heart attack or stroke within the last six months
any other heart or heart valve problems
Loss of vision because of damage to the optic nerve to optic nerve (such as non-arteritic anterior ischemic optic neuropathy or inherited eye disese).
Active stomach ulcers (Also known as peptic/gastric ulcer) or bleeding issues
Liver or kidney problems
Any deformation of the penis, such as angulation or Peyronie 's disease
An erection that lasted more than 4 hours
sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells), multiple myeloma (cancer of bone marrow)
Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption
an alpha blocker (used to treat high blood pressure or urinary symptoms associated with benign prostatic hyperplasia).
other medicines to treat high blood pressure.
a 5- alpha reductase inhibitor (used to treat benign prostatic hyperplasia).
medicines such as ketoconazole tablets (to treat fungal infections) and protease inhibitors for treatment of AIDS or HIV infection.
phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines).
ifampicin, erythromycin , clarithromycin or itraconazole.
other treatments for erectile dysfunction.
Nitric oxide donors such as amyl nitrite ("poppers") Quinidine/procainamide/amiodarone
You will read the patient information leaflet (provided with your medication or by following the relavent link)
The treatment is solely for your own use
All the information you have provided is accurate. You understand our prescribers can only base descions on the information provided and that incorrect information can be detrimental to your health.
We need to ensure that this medicine is suitable for the person it is intended for. Therefore may be required to contact you by phone/video call, If we are unable to speak to you when required your order may be delayed.
You will seek medical advice if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
You will inform your GP with regards to this prescription (It is best practice to inform your GP of any private treatment you receive. All treatment is completely confidential).
I confirm that I give permission for My Pharmacy 365 to inform my doctor of the treatment I have received if the prescriber feels it is clinically necessary