What we treat
Men's Health
Erectile Dysfunction
Premature Ejaculation
Hair Loss
Women's Health
Period Delay
Combined Pill
Mini Pill
Alternatives to the pill
General Health
Asthma
Migraine
Acid Reflux
Weight Loss
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Premature Ejaculation
Do you believe you have the capacity to make decisions about your own healthcare?
Yes
No
Have you been diagnosed with any medical conditions?
Yes
No
Please provide more information, including diagnosis, symptoms and treatment.
Have you ever been diagnosed with a mental health condition?
Yes
No
Please provide more information, including diagnosis, symptoms and treatment.
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Yes
No
Do you suffer from any allergies?
Yes
No
What allergies do you have and what are the symptoms you experience from an allergic reaction?
Is there anything else you would like to include for the prescriber?
Yes
No
Please provide further information:
Do you think you have premature ejaculation?
Yes
No
Since when have you been affected by premature ejaculation?
First sexual encounter
More than 6 months
Less than 6 months
How often are you affected by premature ejaculation?
Every sexual encounter
More than half the time
Less than half the time
How soon after entering your partner do you ejaculate?
Before entering my partner
Less than 2 minutes
Between 2 and 10 minutes
More than 10 minutes
Does premature ejaculation cause distress or difficulties in your sex life?
Yes
No
Can you always get and maintain an erection when you want one?
Yes
No
Do you agree to the following?
You agree to our terms and conditions, privacy policy and acceptable use policy
You will read the Patient Information Leaflet supplied with your medication
The treatment is solely for your own use
You are aware you will be subject to a soft check to validate your identity via Onfido
You have answered all the above questions accurately and truthfully
You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You will inform your GP of this purchase if appropriate
Yes
No
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