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OnlineDoc Treatment
Premature Ejaculation
Only
€
23 per Script
Premature Ejaculation
First Name
Last Name
Email
Date Of Birth
Phone Number
Address
Have you ever taken any medication for your premature ejaculation before?
Choose an option
If Others, Please specify:
Which of the following medication would you like to get prescription for premature ejaculation?
Choose an option
If Others, Please specify:
When did you notice that you are suffering from Premature ejaculation?
*
I NOTICED IT WHEN I STARTED HAVING SEX
THIS IS ONLY A RECENT DEVELOPMENT
Other, (Please Specify)
If Others, Please specify:
What stage do you get ejaculation?
Choose an option
Do you experience PE when you masturbate?
Choose an option
Do you suffer from Erection problem as well along with Premature ejaculation?
*
No
Yes
Have you been treated for Erectile dysfunction?
*
No
Yes
If Yes, Please specify:
Do you have any urinary symptoms or pain, discomfort in your genitals?
*
No
Yes
If Yes, Please specify:
Do you have any underlying angina, heart disease, or any abnormal heart rhythm issues?
*
No
Yes
If Yes, Please specify:
Do you have any underlying bleeding or blood clotting history?
*
No
Yes
If Yes, Please specify:
Do you have any past medical history of seizures , epilepsy or have you ever been on treatment for that?
*
No
Yes
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
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