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Online Consultation for Premature Ejaculation

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indicates a mandatory field that must be completed

I confirm that I suffer from premature ejaculation and cannot control when I ejaculate.

Yes

This question is required and must be answered.

Have you suffered from premature ejaculation for at least the last 6 months?

Yes

This question is required and must be answered.

Do you ejaculate less than 2 minutes after penetration?

Yes

This question is required and must be answered.

Does your premature ejaculation affect the relationship you are in?

Yes

This question is required and must be answered.

Please list the treatments you have tried for premature ejaculation in the past.

Do you suffer from any of the following - prostate problems, panic attacks or thoughts of suicide, bipolar disease, seizures, or heart problems (including heart rythmn problems or palpitations)?

Yes

This question is required and must be answered.

Do you have a history of low blood pressure, fainting, or after lying down do you get dizzy when you stand up?

Yes

This question is required and must be answered.

Do you take any medication, or have any medical conditions?

Yes

This question is required and must be answered.

Do you have any disabilities or special needs that we should be aware of, in order to provide you with the best possible care?

For Example: ADHD, ASD or Learning Difficulties. This will help our clinicians and pharmacy team to allow you access all our services safely.

Yes

This question is required and must be answered.

Do you have any known allergies? E.g. Penicillin, egg protein or peanuts or an allergy to the ingredients in some medication eg lactose?

Yes

This question is required and must be answered.

Do you have any liver or kidney problems including reduced kidney function or chronic liver disease?

Yes

This question is required and must be answered.

Do you give us permission to inform your NHS surgery, about this prescription?

Yes

It is important to tell your doctor of any medication you have been prescribed for them to be able to treat you appropriately, safely and to avoid any drug interactions.

I am over 18 and this is for my sole use. I understand this is a non emergency service. I confirm I have answered all questions accurately and understand the doctor will use this information to prescribe safely for me.

Yes, I confirm

This question is required and must be answered.

By providing us with your details you confirm that you have read, understood and agreed to the legal terms and you consent to the sharing of your data to use our service.
I consent to treatment and an identity check
I give consent for the pharmacist to access and store relevant information from my NHS summary care record which may be needed to safely prescribe.
I agree to read the Patient Information Leaflet supplied with the medication.

Yes, I confirm

This question is required and must be answered.

Online Consultation for Premature Ejaculation

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