Erectile Dysfuntion Consultation - Bury Healthcare Online

Answer these questions to get the most effective clinically proven treatments for you.

Full Name

Date of Birth

Email

Please provide an email address so we can contact you furhter regarding enquiries

Phone Number

Please provide a number so we can contact you furhter regarding enquiries

Gender at Birth

Male

Female

Are you allergic to any of the following medication?

Avanafil (Spedra)

Sildenafil (Viagra)

Tadalafil (Cialis)

Vardenafil (Levitra)

I am not allergic to any of these

Are you, or have you taken any of these Erectile dysfunction treatments?

Herbal / Ayurvedic remedies

Penile pumps

Penile injections (Caverject / Edex / Prostin VR)

Levitra / Vardenafil

Spedra / Avanafil

Sildenafil - Viagra

Tadalafil - Cialis

None of these

Do you take any recitational drugs, including any nitrate based drugs eg: Poppers?

Yes

No

Please provide further details

Do you have any other medical conditions? If so list them below as well as any medications you are currently taking.

If you don't have anything to add, just click next.

DO YOU AGREE AND CONSENT TO THE FOLLOWING?

• I am over the age of 18 years and live in the UK.

• I will familiarise myself with the patient information leaflet included with the medication.

• I will report any side effects and changes in my health to Bury Healthcare Online and/or your GP.

• I will contact Bury Healthcare Online and inform my GP if I experience side effects to any treatment, if my medical history changes, if I start any new medications or if I experience any symptoms or my medical conditions change in any way.

• I shall be the sole user of any medication offered to me through this service.

• I confirm all answers are provided by me, and will be truthful.

I agree to the terms and conditions

Erectile dysfunction

Consultation

We’re Here Whenever You Need Us

Email

customerservice@buryhealthcareonline.co.uk

Contact Us

46 Walmersley Road,

Bury, BL9 6DP

0161 2221024

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