top of page
This site was designed with the
.com
website builder. Create your website today.
Start Now
Home
Phone Consultations
Treatment
Chest Infection
Contraceptive Pill & Patch
Emergency Contraceptive Pill
Urinary Tract Infection
Bacterial Vaginosis
Vaginal Thrush
Chlamydia Treatment
Erectile Dysfunction
Premature Ejaculation
Male Thrush
Hair Loss
Balanitis
Acne
Hand Eczema
Impetigo
Infected Wound
Folliculitis
Cellulitis
Shingles
Chickenpox
Cold Sore
Oral Thrush
Athlete's Foot
Ringworm
Nail Fungal Infection
Scabies Treatment
Ingrown Toenail
Repeat Script
Tick Bite Prophylaxis
Hemorrhoids
Asthma
Migraine
Hay Fever
Sore Throat
Muscle Strains
Sinus Infection
Gastritis & Reflux
Eye Infection
Stye
Ear Infection
Dental Abscess
Angular Cheilitis
Tonsillitis
Mouth Ulcer
Letters
Fit to Return
Health Declaration
Covid19
OnlineDoc Treatment
Erectile Dysfunction Treatment
Only
€
23 per Script
Erectile Dysfunction Treatment
First Name
Last Name
Date of Birth
Email
Phone Number
Address
Please specify from the following medication that you would like to get prescription for?
Choose an option
If Others, Please specify:
Please specify the dose of medication from the list below, if you do not know, please select 'Don't Know'
Choose an option
If Others, Please specify:
Have you ever used this ED treatment previously?
*
No
Yes
Have you ever been prescribed ED treatment before?
*
No
Yes
When did you get your blood pressure checked last time?
Choose an option
Please specify below if you remember the last blood pressure reading? (eg: 120/80 mmHg)
When did you first experienced of your ED?
*
MORE THAN 12 MONTHS AGO
LESS THAN 12 MONTHS AGO
In regards to your erection would you define it fully stiff or soft ?
*
Soft
Stiff
Other, (Please specify Here)
If Other, Please specify:
During the sexual intercourse is your erection sufficient enough for you to manage penetration?
*
YES, I WAS ABLE TO PENETRATE
NO, I COULD NOT PENETRATE
Other, (Please specify Here)
If Other, Please specify:
Do you get morning erection ?(notice an erection upon wakening)?
*
Most Mornings
1-2 per week
1-2 per month
Less frequently
Not any more
Others, Please specify
If Other, Please specify:
Have you ever been diagnosed with psychological or psychiatric issues. for example anxiety, panic attacks or depression, mania, bipolar disorder or schizophrenia)?
*
No
Yes
If Yes, Please specify:
Do you exercise regularly?
*
No
Yes, but not regularly
Yes
Do you smoke cigarettes?
*
No
Yes, (If yes, How many per day or per week. Please specify below)
If Yes, Please specify:
Do you drink alcohol? Please specify
*
No
Yes, (If yes, How many per day or per week. Please specify below)
If Yes, Please specify:
Are you currently taking any prescription, non prescription or illegal drug or herbal medication? and have you recently taken any medication in the last two weeks? please specify.
*
No
Yes, (If yes, How many per day or per week. Please specify below)
If Yes, Please specify:
Do you have a significant past medical or surgical history?
*
No
Yes, (If yes, How many per day or per week. Please specify below)
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
Proceed to Checkout
bottom of page
