Premature Ejaculation - Medcare-healthclinic & Pharmacy

I confirm that I suffer from premature ejaculation and cannot control when I ejaculate*

Yes

No

Have you suffered from premature ejaculation for at least the last 6 months?*

Yes

No

Do you ejaculate less than 2 minutes after penetration?*

Yes

No

Does your premature ejaculation affect the relationship you are in?*

Yes

No

Please list the treatments you have tried for premature ejaculation in the past.*

If none please write none.

Do you suffer from any of the following?*

Prostate problems, panic attacks or thoughts of suicide, bipolar disease, seizures, or heart problems (including heart rhythm problems or palpitations)?

Yes

No

If yes, please give as much information as possible*

Including any diagnoses made by your doctor or specialist

Do you have a history of low blood pressure, fainting, or after lying down do you get dizzy when you stand up?*

Yes

No

If yes, please provide more information*

Are you taking any other prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs?*

Yes

No

If yes, tell us more here*

Do you have any known allergies?*

Yes

No

If yes, tell us more here*

Is there anything else you think we should know?*

Yes

No

If yes, tell us more here*

Would you like us to tell your GP about any care we provide? Ideally your GP should know about any medicines you’re taking.*

Yes

No (This won't affect our review of your order, but we would encourage you to tell your GP)

Please provide your GP details*

Full name, address and post code of your GP surgery

Do you agree to

●1) Read the patient information leaflet included with your medication or accessed via the provided link. ●2) Use the treatment exclusively for yourself. ●3) Confirm the accuracy of all information you've provided, understanding that our prescribers rely on this information to make decisions, and incorrect information could harm your health. ●4) Understand that we may need to contact you by phone or video call to ensure the medicine is suitable. Your order may be delayed if we can't reach you when necessary. ●5) Consent to treatment from MedCare Health Clinic, affirming your mental capacity to make this decision. ●6) The treatment decision is a joint consideration between you and the prescriber, but the final decision and approval rest with the prescriber. ●7) If treatment is deemed unsuitable, you will be directed to alternative care. ●8) Seek medical advice if you experience side effects, start new medications, or if your medical conditions change during treatment. ●9) Inform your GP about this prescription, as it is best practice to notify them of any private treatment. ●10) All treatment remains confidential. ● I confirm that I am over 18 and I agree to the Terms and Conditions

Yes I agree

Name*

First Last

Email*

Date*

Phone

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