Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
What is your gender?
Please provide more detail.
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP.
Have you been diagnosed with any medical conditions?
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you suffer from any allergies?
Please provide details including which allergies and what symptoms you experience.
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Are you male and aged between 18-60 years old?
Please provide more details
Do you often ejaculate within 2 minutes of sexual penetration?
Does premature ejaculation cause you distress and/or interpersonal difficulties?
Has your GP ever advised you that you are not fit enough for any physical or sexual activity?
Do you understand that you cannot drink whilst using Priligy as it can cause drowsiness?
Do you have any problems getting or maintaining an erection that is sufficient for penetration?
Do you suffer from low blood pressure (below 90/50) or experience faints or collapsing because of it?
Have you been suffering from premature ejaculation for more than 6 months?
Are you allergic (hypersensitive) to Priligy (dapoxetine) or any other SSRI antidepressant medicines?
Have you ever suffered from the following?
Do you agree to the following?
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
Do you agree to the following:
If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
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