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Viagra Click And Collect form

Name *

First

Last

Address

Address Line 1

City

State

Zip Code

Email *

Date Of Birth *//

Are you experiencing erectile dysfunction? *

Viagra Connect is only intended for use in men who are experiencing erectile dysfunction (ED) i.e. difficulty in getting and/or maintaining an erection satisfactory for sexual performance.

Has your doctor advised that you are not fit enough for any physical and/or sexual activity? *

Do you feel very breathless or experience chest pain with light or moderate physical activity, such as walking briskly for 20 minutes or climbing two flights of stairs?* *

Have you had a heart attack or stroke within the last 6 months?* *

Do you have any other heart problems or are you under a doctor’s care for any of the following:* *

1) Low blood pressure or uncontrolled high blood pressure
2) Unstable angina (chest pain), irregular heart beat or palpitations (arrhythmia)
3) A problem with one of the valves in your heart (valvular heart disease)
4) A problem where the heart muscle becomes inflamed and does not work as well as it should (cardiomyopathy)
5) Heart problems causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure

Some men are on medication or have certain health conditions that could make Viagra Connect unsafe to take. The following questions help the pharmacist establish if Viagra Connect is suitable for you.

Unsure

Are you taking any medication, including any other erectile dysfunction treatments? *

Please list your medication here:

Are you using drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)? *

Are you taking nitrates (nicorandil or other nitric oxide donors e.g. glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate) for chest pain? *

Are you using drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)? Are you taking riociguat or other guanylate cyclase stimulators for lung problems? *

Are you taking ritonavir (for HIV infection)? *

Are you taking any CYP3A4 inhibitors, e.g. saquinavir (to treat HIV infection), cimetidine (a heartburn treatment), itraconazole or ketoconazole (to treat fungal infections), erythromycin or rifampicin (antibiotics) or diltiazem (for high blood pressure)? *

Are you taking any alpha-blockers, such as alfuzosin, doxazosin or tamsulosin, which are medicines to treat urinary problems due to enlarged prostate (benign prostatic hyperplasia) or occasionally to treat high blood pressure? *

Do you have Peyronie’s disease or any other deformation of the penis? *

Have ever had loss of vision because of damage to the optic nerve (such as non-arteritic anterior ischaemic optic neuropathy [NAION]) or have an inherited eye disease (such as retinitis pigmentosa)? *

Do you have galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption? *

Do you have previously diagnosed hepatic (liver) disease (including cirrhosis of the liver) or severe renal (kidney) impairment? *

Do you have any of the following: sickle cell anaemia, multiple myeloma or leukaemia? Do you have any bleeding issues (e.g. haemophilia) or have active stomach ulcers? *

What pack size do you require?* *

4 Tablets
8 Tablets

Checkboxes

I understand that I should schedule a health check-up with my doctor as soon as I can within 6 months first receiving Viagra Connect to check for underlying medical problems that can sometimes be associated with erectile dysfunction.. 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. Dolans Pharmacies will retain the data provided above for one week to enable your consultation. Anonymised data will be retained for up to two years..