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Male Patients Form

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Male - Erectile Dysfunction Treatment

Put your details

Pharmacy Name*

Pharmacy Location*

Pharmacy EirCode*

Which medication are you looking to get a prescription for?

Please indicate what dose for the list below, if you are unsure, please select 'Don't Know'

Do you have any allergies that you know of?

NO If YES, I HAVE ALLERGIES, please specify:

Have you used your requested ED treatment previously?

YES NO

What age are you?

Have you been prescribed a medication for ED by your GP previously?

YES NO

When was your blood pressure taken last?

If you can remember your last blood pressure result, please enter below (eg: 120/80 mmHg)

Apart from conditions already mentioned in this form, do you suffer from any other medical conditions or have you had any surgical procedures in the past that you feel our Doctors should be aware of?

NO If YES, I HAVE, please specify:

When did you first become aware of your ED?

LESS THAN 12 MONTHS AGO MORE THAN 12 MONTHS AGO

Is your ED problem getting noticeably worse or is it staying same?

STAYS THE SAME GETTING WORSE OVER TIME If other, please specify:

Did your ED present gradually or did it develop all of a sudden?

SUDDENLY GRADUALLY

You last had sexual intercourse?

MORE THAN 12 MONTHS AGO LESS THAN 12 MONTHS AGO

In regards to describing your last erection, would you regard it as fully stiff or was it soft?

SOFT STIFF If other, please specify:

During your last sexual intercourse was your erection sufficient enough for you to manage penetration of your partner?

YES, I WAS ABLE TO PENETRATE NO, I COULD NOT PENETRATE If other, please specify:

Was your erection sustained so that you were able to climax?

YES, I WAS ABLE TO CLIMAX NO, I WAS NOT ABLE TO CLIMAX If other, please specify:

During sexual intercourse, does your erection go soft and inhibit your ability to penetrate your partner?

YES NO

How often would you have a morning erection (notice an erection upon wakening)?

Are you able to ejaculate when you masturbate?

YES NO

During periods of masturbation, would your penis's erection be hard or soft?

HARD SOFT

Did you ever receive a diagnosis or treatment for any psychological issues (such as anxiety, panic attacks or reactive depression), or for any psychiatric issues (such as, mania, bipolar disorder or schizophrenia)?

NO If YES, please specify:

Do you find that your ED impacts your relationship?

YES NO Not currently in a relationship

Do you exercise on a regular basis?

NO If YES, I DO, please specify:

Are you currently a smoker?

Do you drink alcohol (1 unit = 125ml wine, ½ pint beer, bar measure of spirits)?

Do you currently take any prescription medications?

NO If YES, I AM, please specify:

Do you currently take any non-prescribed or herbal medication?

NO If YES, I AM, please specify:

Do you currently take any recreational/illegal drugs?

NO If YES, I AM, please specify:

Gender

MALE

What height are you? (enter as centimeters)

What weight are you? (enter as kg)

The prescription is digitally sent to a pharmacy of your choosing (place Pharmacy details below eg: Stacks Pharmacy / Bettystown)

I confirm that I fully understand and have read completely all questions in this form and all of my answers are true and accurate, to the best of my knowledge.

I CONFIRM

Complete the prescription form below. If the doctor determines that an prescription is not appropriate for your case, you will be refunded.

EXPRESS SickCert: Prescription within 24hrs sent via email. 29.99 EUR

*This will be reviewed and signed by an Irish doctor and is emailed to you within 24 hours.

RECOMMENDED: Prescription will be prioritised in the queue and sent via email. 24.99 EUR

*This will be reviewed and signed by an Irish doctor, sent via email and your request will be at the top of the request queue.

EMAIL: Prescription will be sent via email within 2-3 working days 19.99 EUR

*This will be reviewed and signed by an Irish doctor and sent via email, usually delivered within 2-3 working days.

I confirm that I am not seriously unwell and I do NOT have any of the following symptoms: chest pain, shortness of breath, unable to swallow fluids or saliva, weakness or numbness down one side of my face or limbs or body, slurred speech. I confirm I do not think I need to see a GP. I confirm that this is not a replacement for a doctor's visit. I have read, understood and agree with the information in the terms of service and consent to the use of information in accordance with the (privacy policy).

I CONFIRM I DO NOT CONFIRM

GET HEALTHCARE ONLINE LIMITED.

Get Healthcare is a one-stop telehealth platform based in Ireland. We offer only online medical services to make it easy for busy working professionals and university students to catch up with their minor healthcare needs in a seamless and hassle-free manner.

Address: Ludgate Hub, Old Bakery, Townshend Street,
Skibbereen, Co. Cork, P81T324, Ireland

Support phone number: 0212455185

Male Patients Form

Male - Erectile Dysfunction Treatment

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