Premature Ejaculation

Risk Assessment

Have you been diagnosed with erectile dysfunction by a doctor?

Yes

Do you have any heart problems? This includes (but is not limited to):
Angina and heart attack

Yes

Risk Assessment

Do you agree to the following?

You will read the patient information leaflet supplied with your medication.

You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.

The treatment is solely for your own use.

You have answered all the above questions accurately and truthfully.

You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes

Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Yes

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