Male Patients Form 2

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Male - Premature Ejaculation Treatment

Put your details

Pharmacy Name*

Pharmacy Location*

Pharmacy EirCode*

Did you ever receive any medication or therapy to treat your PE?

What medical treatment for PE would you like to apply for?

EMLA PRILIGY If other, please specify:

When did you first notice your Premature Ejaculation (PE) was an issue of concern to you?

I NOTICED IT WHEN I STARTED HAVING SEX THIS IS ONLY A RECENT DEVELOPMENT If other, please specify:

How often would you experience an episode of PE?

EVERYTIME I HAVE SEXUAL INTERCOURSE ONLY WHEN I HAVE SEXUAL INTERCOURSE WITH A NEW PARTNER If other, please specify:

At what point does an ejaculation occur?

When you masturbate, does an episode of PE happen?

Have you an idea of what might cause you to have an episode of PE?

NO If YES, I DO, please specify:

Have you noticed any difficulty while initiating or maintaining an erection prior to an ejaculation?

YES If YES, I HAVE, please specify:

Did you ever receive a diagnosis or treatment for erectile dysfunction?

NO If YES, I DO, please specify:

Have you ever been advised to avoid or abstain from sexual intercourse (either by a Doctor, Nurse or Pharmacist)??

NO If YES, I HAVE, please specify advice given:

Do you notice any pain or discomfort in your genitals, after you pass urine or ejaculate?

NO If YES, I HAVE, please specify:

Apart from conditions already mentioned in this form, do you suffer from any other medical conditions or have you had any surgical procedures in the past that you feel our Doctors should be aware of?

NO If YES, I WAS, please specify:

Have you a history of low blood pressure, dizziness, or feeling faint when you stand up from a sitting position?

NO If YES, I DO, please specify:

Have you been diagnosed as suffering from any heart conditions, for example angina, irregular heart rhythm, etc.?

NO If YES, I DO, please specify:

Have you been diagnosed as having a bleeding or clotting disorder?

NO If YES, I DO, please specify:

Do you suffer from either migraines or severe headaches?

NO If YES, I DO, please specify:

Have you ever been diagnosed or received treatment for epilepsy or have you ever has a seizure?

NO If YES, I DO, please specify:

Genger

MALE

What height are you? (enter as centimeters)

What weight are you? (enter as kg)

What age are you?

The prescription is digitally sent to a pharmacy of your choosing (place Pharmacy details below eg: Stacks Pharmacy / Bettystown)

I confirm that I fully understand and have read completely all questions in this form and all of my answers are true and accurate, to the best of my knowledge.

I CONFIRM

Complete the prescription form below. If the doctor determines that an prescription is not appropriate for your case, you will be refunded.

EXPRESS SickCert: Prescription within 24hrs sent via email. 29.99 EUR

*This will be reviewed and signed by an Irish doctor and is emailed to you within 24 hours.

RECOMMENDED: Prescription will be prioritised in the queue and sent via email. 24.99 EUR

*This will be reviewed and signed by an Irish doctor, sent via email and your request will be at the top of the request queue.

EMAIL: Prescription will be sent via email within 2-3 working days 19.99 EUR

*This will be reviewed and signed by an Irish doctor and sent via email, usually delivered within 2-3 working days.

I confirm that I am not seriously unwell and I do NOT have any of the following symptoms: chest pain, shortness of breath, unable to swallow fluids or saliva, weakness or numbness down one side of my face or limbs or body, slurred speech. I confirm I do not think I need to see a GP. I confirm that this is not a replacement for a doctor's visit. I have read, understood and agree with the information in the terms of service and consent to the use of information in accordance with the (privacy policy).

I CONFIRM I DO NOT CONFIRM

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Male Patients Form 2

Male - Premature Ejaculation Treatment

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