Medical Assessment Safe Medication Purchase for Erectile Dysfunction Complete our form to ensure the safe and reliable purchase of medication for Erectile Dysfunction. Your health and privacy are our top priorities. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 4About YouFull Name *FirstLastDate of Birth *Phone Number *Email *Are you male and aged between 18-75? *YesNoRequirements: Must be a male and be between the ages of 18 and 75.We are unable to supply you with medication for erectile dysfunction. Please consult your GP or doctor. Do you smoke or drink? *YesNoYou're eligible for treatment, but alcohol and smoking can worsen erectile dysfunction. Have you taken Viagra (sildenafil), Levitra (vardenafil), Nipatra, Spedra or Cialis (tadalafil) at least 4 times previously without any side effects? *YesNoAs you have not previously taken any erectile dysfunction medication, we will not be able to supply you with a high-strength treatment. NextYour SymptomsDo you have trouble achieving or maintaining your erection? *YesNo It does not appear that you have erectile dysfunction. We are unable to supply you with treatment. Please consult your GP or doctor for more information. Your HealthDo you have any allergy to Viagra (sildenafil), Levitra (vardenafil), Spedra (avanafil) or Cialis (tadalafil) or have you experienced any adverse reaction to any erectile dysfunction medication previously? *YesNoWe are unable to supply you with medication for erectile dysfunction. Please consult your GP or doctor. Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure? *YesNoIf you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.We are unable to supply with medication for erectile dysfunction if you have high blood pressure. Please consult your GP or doctor for more information. Do you have low blood pressure (below 90/50)? *YesNoIf you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.We are unable to supply with medication for erectile dysfunction if you have low blood pressure. Please consult your GP or doctor for more information. Do you suffer from depression for which you have not seen a GP? *YesNo We are unable to supply you with medication for erectile dysfunction at this time. Please consult your GP or doctor for more information. Have you been advised to avoid strenuous exercise? *YesNo We are unable to supply you with medication for erectile dysfunction at this time. Please consult your GP or doctor for more information. Have you ever suffered from any of the problems listed below? *YesNo Any heart problems including angina, chest pain, heart failure, irregular heartbeats, heart attack (myocardial infarction), left-ventricular outflow obstruction, cardiomyopathy or valvular heart disease (e.g. aortic stenosis) Stroke Sight loss due to poor circulation Sight loss because of non-arteritic anterior ischemic optic neuropathy (NAION) Blood problems such as haemophilia, sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells) Stomach ulcers (e.g. peptic/gastric ulcer) Liver problems Kidney problems An erection that lasted more than 4 hours Any physical condition affecting the shape of the penis (e.g. angulation, Peyronie’s disease and cavernosal fibrosis) Inherited eye disease - retinitis pigmentosa Multiple myeloma (cancer of the bone marrow) Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption Any serious medical condition which may require immediate hospitalisation We are unable to supply you with medication for erectile dysfunction at this time. Please consult your GP or doctor for more information. Would you have any difficulty walking at a fast pace for 5 minutes? *YesNo We are unable to supply you with medication for erectile dysfunction at this time. Please consult your GP or doctor for more information. NextYour MedicationAre you currently taking any medication (over-the-counter or prescription) or any recreational drugs? *YesNoAre you taking any of the following? *YesNo Any heart problems including angina, chest pain, heart failure, irregular heartbeats, heart attack (myocardial infarction), left-ventricular outflow obstruction, cardiomyopathy or valvular heart disease (e.g. aortic stenosis) Stroke Sight loss due to poor circulation Sight loss because of non-arteritic anterior ischemic optic neuropathy (NAION) Blood problems such as haemophilia, sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells) Stomach ulcers (e.g. peptic/gastric ulcer) Liver problems Kidney problems An erection that lasted more than 4 hours Any physical condition affecting the shape of the penis (e.g. angulation, Peyronie’s disease and cavernosal fibrosis) Inherited eye disease - retinitis pigmentosa Multiple myeloma (cancer of the bone marrow) Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption Any serious medical condition which may require immediate hospitalisation Any other erectile dysfunction treatments that are not Viagra (sildenafil), Levitra (vardenafil), Cialis (tadalafil), Spedra (avanafil) Medicinal nitrates such as glycerol trinitrate, isosorbide mononitrate or isosorbide dinitrate (including oral, transdermal and sublingual) Recreational drugs prohibited by law (Class A, B or C) Recreational nitrates such as amyl nitrate also known as "poppers" Alpha-blockers (used to treat high blood pressure or urinary symptoms associated with benign prostatic hyperplasia, including tamsulosin, doxazosin, prazosin, terazosin & indoramin) Medicines to treat high blood pressure Warfarin - used prevent heart attacks, strokes, and blood clots Antivirals including (Atazanavir, etravirine, fosamprenavir, indinavir, nelfinavir, ritonavir, saquinavir) Nicorandil Anti-fungal medication such as ketoconazole or itraconazole Quinidine/procainamide/amiodarone Theophylline Erythromycin/clarithromycin/cimetidine Phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines) Riociguat Rifampicin We are unable to supply you with medication for erectile dysfunction at this time. Please consult your GP or doctor for more information. Are you taking any medicines known as nitrates (often taken for chest pain/angina) or nitric oxide donors ('poppers')? *YesNo Often taken for chest pain/angina Can be administered as a spray, tablet or patch Includes glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate We do not advise any recreational drug use with PDE 5 inhibitors, especially nitric oxide donors such as ‘poppers’ which may lead to a dangerous fall in your blood pressure. We are unable to supply you with treatment. Please consult your GP or doctor for more information. Medication Name *Select MedicationViagraSildenafilTadalafilNextAgreementDo you understand that erectile dysfunction can be associated with a number of contributing health conditions e.g. hypertension, diabetes mellitus, high cholesterol or cardiovascular disease and you should consult your doctor within 6 months of starting treatment for a clinical review? *YesNo You must agree to this before continuing. If you need assistance, please contact our customer support. In the rare event, I obtain a prolonged erection of more than 4 hours or experience any sudden visual impairment, I agree that I will seek immediate medical assistance. *YesNo You must agree to this before continuing. If you need assistance, please contact our customer support. Do you agree to the following? *YesNo 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, you start new medication and/or 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 You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber You must agree to this before continuing. If you need assistance, please contact our customer support. I agree to the Terms & Conditions and Privacy Policy *I agreePlease read these Terms and Conditions carefully before using our website drugs4delivery.com, associated applications, and services operated by Drugs4Delivery. 1. Acceptance of Terms By accessing and using our services, you agree to be bound by these Terms and Conditions, all applicable laws and regulations, and agree that you are responsible for compliance with any applicable local laws. If you do not agree with any of these terms, you are prohibited from using or accessing this site. 2. Privacy Your privacy is very important to us. Our Privacy Policy, which also governs your visit to our site, can help you understand how we collect and use your personal information. Please read it here: Privacy Policy. 3. Use License Permission is granted to temporarily download one copy of the materials (information or software) on Drugs4Delivery’s website for personal, non-commercial transitory viewing only. 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Information We Collect We may collect and process the following data about you: Personal Information: Your name, address, email address, telephone number, and other contact details. Health Information: Prescription details, medical history, and other health-related information necessary for us to provide you with our services. Transaction Data: Details about payments to and from you and other details of products and services you have purchased from us. Technical Data: Internet protocol (IP) address, your login data, browser type and version, time zone setting and location, browser plug-in types and versions, operating system and platform, and other technology on the devices you use to access this website. Usage Data: Information about how you use our website, products, and services. How We Use Your Information We use information held about you in the following ways: To Fulfil Our Services: To dispense and deliver prescriptions and other products. 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