Viagra Connect Consultation Form

By completing the online consultation form in advance, your pharmacist can have your completed form and medication ready and waiting for you when you arrive at the pharmacy.

Viagra Connect is only intended for men aged 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 must not be supplied to men who do not have ED. It is not essential that the man has a previous diagnosis of ED from their GP/Urologist.

If not prescribed by your doctor please make an appointment as soon as he can within the first 6 months of starting to use Viagra Connect, to ensure that your erection problems are not caused by any serious health condition.

First Name *

Last Name *

Street Address

Address Line 1

Address Line 2

County

Eircode

Country

The reason we ask for your address is that we need it to enter onto our Patient Medical Record (PMR) along with the supply of the morning after pill

Date Of Birth *

Medical Card Number

This service is open to women 18 years old and over. If you are under 18 please call any of our pharmacies to discuss your options (Note: under 18’s can still purchase the morning after pill from Q Heatlh Pharmacy, but must visit Q Health Pharmacy first).

ADDITIONAL INFORMATION

Is the medication for your own use?YesNo

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

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?YesNo

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

Do you have any other heart problems or are your under a doctor's care for any of the following:YesNo

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

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

Are you taking riociguat or other guanylate cyclase stimulators for lung problems?YesNo

Are you taking ritonavir (for HIV infection)?YesNo

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 (antibiotics) or diltiazem (for high blood pressure)?YesNo

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?YesNo

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

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)?YesNo

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

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

Do you have any of the following: sickle cell anaemia, multiple myeloma or leukaemia?YesNo

Do you have any bleeding issues (e.g. haemophilia) or have active stomach ulcers?YesNo

Are you taking any other medication?YesNo

If so please list below:

Do you suffer from any illnesses, conditions or allergies?YesNo

If so please list below

Contact Phone Number *

Email Address *

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