Premature Ejaculation Consultation Form

Personal Details

What sex were you assigned at birth?This question is required. *MaleFemale

Please visit your GP at the earliest convenience. We are unable to supply you with this medication at this time.

What is your Date of Birth? *

Month

Day

Year

Does premature ejaculation cause personal distress and/or relationship troubles with your partner? *YesNo

Please visit your GP at the earliest convenience. We are unable to supply you with this medication at this time.

Do you drink alcohol? *YesNo

Symptoms

Do you ejaculate in less than 2 minutes? *YesNo

Do you experience pain upon ejaculation? *YesNo

We are unable to supply you with treatment at this time as this symptom may indicate another condition which needs further investigation by your GP.

Your Health

Do you suffer from low blood pressure less than 90/60mmhg? *YesNo

We are unable to supply you with treatment at this time, please visit your GP.

Do you suffer from any of the following conditions?

Heart problems or a history of heart problems
Moderate to severe liver problems
Uncontrolled high blood pressure
History of fainting, dizziness, or low blood pressure
Taking medications for depression, migraines, or psychiatric disorders known as monoamine oxidase inhibitors (MAOIs)
History of bleeding or clotting disorder
Kidney problems
Prostate Problems
Lactose intolerance

Select Option *YesNo

We are unable to supply you with treatment at this time, please visit your GP.

Please select your preference. *Prefer taking a tabletPrefer topical treatment

Have you used Priligy (Dapoxetine) in the past? *YesNo

Have you had an allergic reaction to Priligy (Dapoxetine) before? *YesNo

Do you take any over the counter, herbal, recreational or prescription medications? *YesNo

We are unable to supply you with treatment at this time, please visit your GP.

Please provide details of what you are currently taking? *

Please agree or disagree to the following :

I understand that in the case I encounter any side effects during the treatment, such as mood changes or seizures, it is crucial to stop the treatment immediately and seek urgent medical assistance from a doctor?
I understand taking Priligy with erectile dysfunction treatment can cause a significant drop in blood pressure and can be dangerous?
I will read the Patient information leaflet before starting my medication
I will contact my GP or pharmacy if I suffer from any adverse effects to the medication
I have answered all the questions and statements truthfully and understand if I have falsified information I may be putting my own health in jeopardy
I understand that the prescriber will review my information and based on my answers will decide whether or not the medication is safe for me
I understand that the pharmacist may require access to my Summary Care Records (SCR) to double check any contraindicating medications I may be on. In this case I consent to the pharmacist and solely the pharmacist to view my SCR.
I agree to notify my GP of the treatment of the treatment I have requeste.

Select Option *I acceptI don't accept

Medications *Continue

Select Medicine *EMLA Cream 5%Priligy

EMILA Cream Select Dose (mg) *

Pack Size 5g *

EMLA Cream 5g

EMLA Cream 5x5g (pack size) *

EMLA Cream 5x5g

Priligy Select Dose (mg) *

Priligy pack 30mg (pack size) *

Priligy 30mg

Priligy pack 60mg (pack size) *

Priligy 60mg

proceed to Checkout *Continue to Checkout

Your Name *

Email Address *

Phone *

Shipping Address

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Credit / Debit Card *