Your full name: *

Date of Birth: *

Are you experiencing erectile dysfunction? *

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

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? *

Have you had a heart attack or stroke within the last 6 months? *

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

If yes, please confirm:

Are you taking nitrates (nicorandil or other oxide donors e.g. glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate) for chest pain? *

Are you taking riociguat or other guanylate cyclase stimulators for lung problems? *

Are you taking ritonavir (for HIV infection)? *

Are you taking 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)? *

Are you taking 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? *

Do you have Peyronie's disease or any other deformation of the penis? *

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? *

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

If Yes, please list here:

Are you using drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)? *

Have you 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 any other illnesses, medical conditions, or allergies? *

If Yes, please list here:

What pack size would you like? *

By entering your phone number here, you are consenting to our Pharmacist contacting you by phone to carry out a consultation. (If you do not consent to being contacted and would prefer to complete the consultation in store, please leave this box blank)

Select location for collection: *

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. By filling out this form you are consenting to your consultation form being kept securely on the pharmacy premises for two years as required by Irish law. *