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OnlineDoc Treatment
Balanitis
Treatment
Only
€
23 per Script
Balanitis Treatment
First Name
Last Name
Date Of Birth
Email
Phone Number
Address
Please Upload some phots of your current issue. (Optional)
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How long do you have it?
Has the leasion spread?
*
No
Yes
If Yes, Please specify:
Are there any obvious factors that either trigger or relieve the problem?
*
No
Yes
If Yes, Please specify:
Which one of the below signs do you have? Please select
*
Required
Pain and irritation on the head of your penis.
Discoloration or discolored patches on your penis
Itching under your foreskin
Swelling
Areas of shiny or white skin on your penis
White discharge under your foreskin
A foul smell
Pain while urinating (peeing)
Other (Please Specify)
If Others, Please specify:
Do you have a significant past medical or surgical history?
*
No
Yes
If Yes, Please specify:
Are you allergic to any medication or any other substance?
*
No
Yes
If Yes, Please specify:
Please provide the name and address of the pharmacy where you'd like to pick up your medications.
I confirm that the answers I have provided for the above questions are true and accurate to the best of my knowledge.
*
I Confirm
I Do Not Confirm
I confirm and agree that any treatment prescribed for me is for my personal use only.
*
I Confirm
I Do Not Confirm
I fully understand the side-effects of the treatment options, their effectiveness and alternative options and am happy to continue with my request.
*
I Confirm
I Do Not Confirm
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