Viagra

Erectile Dysfunction (ED) is the inability to get and/or maintain an erection when sexually aroused; this affects sexual relations and is persistent in nature. This service is designed to help and assist people in this situation.

Viagra is only intended for males 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 is not suitable or advised for people who do not have Erectile Dysfunction (ED).

Viagra is available in Drimoleague Pharmacy without a prescription, subject to meeting certain criteria.

Viagra Connect Information Leaflet

You can fill out this form from the comfort of your home, and we will prepare your medication for you based on the answers you have provided. We will contact you when it’s ready.

Please be honest and if you are unsure about any of your answers please verify the information with your GP before using the service.

Please note the “click & collect” online order service is subject to availability and must be within the pharmacy opening hours. Please check the pharmacy opening hours before proceeding.

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

Is this medicine for your own use?

Yes No

Customers must attend in person to collect the medication.

Gender

I confirm I am male.

Full Name

Date of Birth

This product is only available to males aged 18 or older. If you are under 18, please contact your GP to discuss your options.

Address

Email Address

Contact Number

By entering your phone number here, you are consenting to the pharmacist contacting you by phone if the pharmacist needs to discuss your questionnaire or to carry out a phone consultation. If you do not consent to being contacted and want to complete the consultation in the pharmacy, please visit the pharmacy in person during opening hours: Monday - Saturday 9am - 6pm

Are you experiencing erectile dysfunction?

Yes No

General Health

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?

Yes No

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

Yes No

Do you suffer from low blood pressure or uncontrolled high blood pressure?

Yes No

Do you suffer from unstable angina (chest pain), irregular heartbeat or palpitations (arrhythmia)?

Yes No

Do you suffer from a heart problem causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure?

Yes No

Do you suffer from problem where the heart muscle becomes inflamed and does not work as well as it should (cardiomyopathy)?

Yes No

Current Medications

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

Yes No

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

Yes No

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

Yes No

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)?

Yes No

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?

Yes No

Are you taking other medications?

Yes No

If you answered yes above, please specify:

Medical History & Current Medications

Do you have Peyronies disease or any other deformation of the penis?

Yes No

Have you 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)?

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

Do you have any illnesses, medical conditions, or allergies?

Yes No

Please choose the size of the pack

4 pack 8 pack

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 speak with the pharmacist before Viagra Connect will be supplied. Drimoleague Pharmacy will retain the data provided above for one week to enable your consultation. Anonymised data will be retained for up to two years.

I confirm I understand that I need to schedule a health check with my GP within 6 months of first receiving Viagra to check for underlying medical problems that can sometimes be associated with erectile dysfunction.

Viagra

General Health

Current Medications

Medical History & Current Medications

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