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This questionnaire forms the basis of your online consultation. Please be honest and if you are unsure about any of your answers please verify the information with your GP before using the service:

Viagra Connect is only intended for men 18 years and older who are experiencing erectile dysfunction (ED) (i.e., difficulty in getting and/or maintaining an erection satisfactory for sexual performance). This product is not suitable or advised for men who do not have erectile dysfunction (ED).

- I am 18 years old or above.

- I am using this service on my own behalf and of my own free will. Any treatment or advice is for my sole use only.

I confirm the above statements are true (tick to confirm)

There is a fatal reaction between ED/Viagra Connect tablets and nitrate medication, including GTN spray.

Do not buy ED medication from us if you have a GTN spray, tablets, patch, gel, or cream or take nicorandil or any nitrate tablets (usually prescribed for heart conditions). You need to see your GP to discuss alternative options.

Please confirm that you have read and understood the above

Yes, I understand the fatal reaction (tick to confirm)

No, I do not understand this (tick to confirm)

Erectile Dysfunction (ED) is where a man cannot get or maintain an erection when sexually aroused and this affects his sexual relationship with his partner, and this is a persistent problem. This service is designed to help and assist men in this situation.

Confirmation that I have trouble getting or maintaining an erection

I confirm I am seeking treatment for ED because I persistently cannot get or maintain an erection when sexually aroused. (tick to confirm)

Please detail any surgeries or any other medical conditions you/attendee have had or list any allergies you/attendee suffer from:

I confirm that the information I have given is correct to the best of my knowledge. I am aware that I will need to attend the pharmacy in person and to speak with the pharmacist before Viagra Connect will be supplied. I am aware that CarePlus Pharmacy will retain this questionnaire for a period of two years in line with Data Protection Requirements.

Service

Viagra connect

Date

Time

Duration

15 Min

Pharmacy

Your booking is now Confirmed

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