Erectile Dysfunction > Erectile Dysfunction Request

Erectile Dysfunction Request

Treatment Eligibility

This consultation is only available to adults aged 18 years or over.

Are you aged 18 or over?(Required)

Yes

Warning — Cannot Continue

You must be 18 or over

Erectile dysfunction treatment can only be supplied to adults aged 18 years or over.

Are you experiencing erectile dysfunction symptoms?(Required)

Yes

Warning — Cannot Continue

Not suitable at this time

Erectile dysfunction medication is not suitable if you are not experiencing any symptoms.

Patient Details

Please provide your personal details so we can confirm your identity and contact you regarding your consultation. This information is required for safe prescribing and pharmacy records.

Full Name(Required)

Enter your full legal name.

Date of Birth(Required)

DD slash MM slash YYYY

Your date of birth is required to verify you are over 18 and eligible for treatment.

Email Address(Required)

We will use this email address to send consultation updates and treatment information.

Phone Number(Required)

A pharmacist may contact you if further clinical review is required.

Home Address(Required)

Street Address Address Line 2 City Post Code

Clinical Assessment

These questions help the pharmacist understand your symptoms and determine whether treatment may be appropriate.

How long have you had symptoms?(Required)

Less than 3 months

3–12 months

More than 12 months

Have you used erectile dysfunction medication before?(Required)

Yes

Please Note

First treatment request

A pharmacist may carry out additional review if this is your first erectile dysfunction treatment.

Which medication have you used?(Required)

Medication name(Required)

Medical Safety

Do you take nitrate medication (e.g. GTN, isosorbide)?(Required)

Yes

Warning — Cannot Continue

Unsafe medication combination

Erectile dysfunction medication must not be used with nitrate medicines due to the risk of a dangerous drop in blood pressure.

Have you had a heart attack or stroke in the last 6 months?(Required)

Yes, within the last 6 months

Recent cardiovascular events may affect treatment safety.

Warning — Cannot Continue

Treatment requires medical review

Erectile dysfunction treatment may not be suitable following a recent heart attack or stroke.

Have you been diagnosed with high or low blood pressure?(Required)

Yes

Not sure

Warning — Please Read

Blood pressure review required

Your blood pressure history will require pharmacist review before treatment can be approved.

Has a doctor advised you to avoid sexual activity?(Required)

Yes

Warning — Cannot Continue

Treatment not suitable online

If sexual activity has been medically advised against, erectile dysfunction treatment should not be supplied through this consultation service.

Do you have any medication allergies?(Required)

Yes

List your allergies(Required)

GP Details and Consent

GP Practice Name

Enter the name of your GP surgery if known.

GP Practice Postcode

Enter the postcode of your GP surgery if known.

Consent to contact my GP if needed(Required)

Yes

I consent to the pharmacy contacting my GP practice if needed to support my treatment.

Warning — Please Read

GP notification recommended

We recommend informing your GP for continuity of care. A clinician may discuss this with you.

Declarations

Information Accuracy(Required)

I confirm my information is accurate

Please ensure all details are correct before submitting.

Erectile Dysfunction Consultation Consent(Required)

I consent to this consultation

I consent to the pharmacy reviewing my information to assess whether treatment is appropriate and safe to supply.

I agree to the Privacy Policy

Please review how we collect, use and protect your personal data.

CAPTCHA

What to expect

Complete this confidential consultation so our pharmacist can review your details and confirm whether treatment is suitable.

Confirmation email sent after submission
Reviewed by our pharmacist
Outcome and next steps sent by email

Next steps

Complete the confidential consultation

Check your email for confirmation

Our pharmacist reviews your details

We email the outcome and next steps

Erectile Dysfunction Request

Treatment Eligibility

You must be 18 or over

Not suitable at this time

Patient Details

Clinical Assessment

First treatment request

Medical Safety

Unsafe medication combination

Treatment requires medical review

Blood pressure review required

Treatment not suitable online

GP Details and Consent

GP notification recommended

Declarations

What to expect

Next steps

Important information

Regulatory details