Viagra Connect Consultation

This confidential form will help the pharmacist assess if this treatment is suitable for you

Your Name*

Email Address*

Contact Phone Number

Date of Birth* (Must be over 18)

Are you experiencing erectile dysfunction (difficulty getting or maintaining an erection)?*

How long have you been experiencing this issue?

Are you able to achieve any erection at all?

Has your doctor ever advised that you are not fit enough for sexual or physical activity?*

Do you experience chest pain or breathlessness with light activity (e.g. walking briskly or climbing stairs)?*

Have you had a heart attack or stroke within the last 6 months?*

Are you currently taking nitrates or recreational drugs such as “poppers” (amyl nitrite)?*

Are you currently taking any medication (including other erectile dysfunction treatments)?*

Please provide details of your medication

What pack size would you prefer?