Erectile Dysfunction Consultation Form

As treatment for erectile dysfunction consists of a prescription-only medication, we need to ensure you are safe & suitable to use it.

Your information will NEVER be shared with any 3rd parties beyond the pharmacies and prescribers we use. Information is only ever shared with relevant professionals for your treatment.

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PLEASE NOTE

We will require a form of ID to verify you are over the age of 18 and that we are providing treatment for the intended person. This will be on the last page of the form. Please wait for your file to upload before pressing submit.

When you submit your form, you will be invited to create a free online account on our website. Your form will be screened by a prescriber and we will contact you with the outcome within 24 to 48 hours.