Hynes Pharmacy

Viagra Connect Consultation Form

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

First Name: *

Surname: *

Email: *

Phone: *

Date of Birth: *

This product is only available to men aged 18 or over. (If you are under 18 please contact your GP to discuss your options)

Address: *

Health Questions

Are you experiencing erectile dysfunction? *

Viagra Connect is only intended for use in men who are experiencing erectile dysfunction (ED) i.e. difficulty in getting and/or maintaining an erection satisfactory for sexual performance.

Yes

No

Has your doctor advised that you are not fit enough for any physical and/or sexual activity?* *

Yes

No

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 have any other heart problems or are you under a doctor’s care for any of the following:

Low blood pressure or uncontrolled high blood pressure

Unstable angina (chest pain), irregular heart beat or palpitations (arrhythmia)

A problem with one of the valves in your heart (valvular heart disease)

A problem where the heart muscle becomes inflamed and does not work as well as it should (cardiomyopathy)

Heart problems causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure

None of the above

Are you taking any medication, including any other erectile dysfunction treatments? *

Yes

No

Please list your medication here:

Are you taking any of the following:

Drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)?

Nitrates (nicorandil or other nitric oxide donors e.g. glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate) for chest pain?

Drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)? Are you taking riociguat or other guanylate cyclase stimulators for lung problems?

Ritonavir (for HIV infection)?

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)?

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?

None of the above

Do you have any of the following:

Peyronie’s disease or any other deformation of the penis?

Have 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)?

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

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

Do you have any of the following: sickle cell anaemia, multiple myeloma or leukaemia? Do you have any bleeding issues (e.g. haemophilia) or have active stomach ulcers?

None of the above

What pack size do you require? *

4 Pack

8 Pack

I understand that I should schedule a health check-up with my doctor as soon as I can within 6 months first receiving Viagra Connect to check for underlying medical problems that can sometimes be associated with erectile dysfunction.. 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 to speak with the pharmacist before Viagra Connect will be supplied. *