Tadalafil Daily Consultation

This assessment WILL TAKE approximately 3 minutes

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Your Health Consultation

To ensure your medication is safe and suitable for you, we need to collect some essential health information. Please complete the consultation form as truthfully and accurately as possible to allow our prescribers to safely dispense your treatment.

Please provide your full name*

First Last

Gender*

Male

Female

Other

Address*

Street Address Address Line 2 City Postcode

Email*

Phone*

Date of Birth*

Day

Month

Year

Medical Questions

Please ensure all information is accurate and complete to help us personalise your weight loss plan.

Are you between 18 and 70 years old?*

Yes

Do you have any diagnosed medical conditions?*

Yes

Please provide details.*

Do you take any medication? This can be prescribed medication or any other over the counter or herbal medicines?*

Yes

Please provide details.*

Are you taking any medicines known as nitrates (often taken for chest pain/angina) or nitric oxide donors ('poppers')?*

Yes

Do you suffer from any allergies? This includes any medication or ingredients you may be allergic to?*

Yes

Please provide details.*

Have you taken Viagra (sildenafil), Levitra (vardenafil), Nipatra, Spedra or Cialis (tadalafil) previously without any side effects?*

Yes

Do you have trouble achieving or maintaining your erection?*

Yes

Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure?*

Yes

Do you have low blood pressure (below 90/50)?*

Yes

Have you been advised to avoid strenuous exercise?*

Yes

Would you have any difficulty walking at a fast pace for 5 minutes?*

Yes

Do you suffer from depression for which you have not seen a GP?*

Yes

Have you ever been diagnosed with one of the following conditions:*

Any heart problems including angina, chest pain, heart failure, irregular heart beats, heart attack (myocardial infarction), left-ventricular outflow obstruction, cardiomyopathy or valvular heart disease (e.g.aortic stenosis).

Stroke

Sight loss due to poor circulation

Sight loss because of non-arteritic anterior ischemic optic neuropathy (NAION)

Blood problems such as haemophilia, sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells)

Stomach ulcers (e.g. peptic/gastric ulcer)

Liver problems

Kidney problems

An erection that lasted more than 4 hours

Any physical condition affecting the shape of the penis (e.g. angulation, Peyronie’s disease and cavernosal fibrosis)

Inherited eye disease - retinitis pigmentosa

Multiple myeloma (cancer of the bone marrow)

Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption

Any serious medical condition which may require immediate hospitalisation

None of the above

Please provide any additional information that you think we need to know about to safely prescribe your medication (optional)

Declaration and Consent

Please read the declaration below carefully. By submitting this consultation, you confirm that you understand and agree to the following statements.

I understand that there are a number of conditions that can cause erectile dysfunction e.g. hypertension, diabetes mellitus, high cholesterol or heart disease and I should consult my doctor within 6 months of starting treatment for a clinical review.*

I confirm the above

Yes

In the rare event, I obtain a prolonged erection of more than 4 hours or experience any sudden visual impairment, I agree that I will seek immediate medical assistance.*

I confirm the above

Yes

By submitting this consultation, I confirm that I am aged between 18 and 80 years old and that I am completing this form for myself.

I confirm that the medication requested is for my own personal use only and will not be shared with any other person.

I confirm that all the information I have provided is true, complete, and accurate to the best of my knowledge, and that I have not deliberately withheld any relevant medical information.

I confirm that I have the capacity to make decisions about my own health and treatment.

I will read the patient information leaflet supplied with any medication issued and follow the instructions provided.

I confirm that I am not aware of any allergies, contraindications, or medical conditions that would make this medication unsafe for me, unless I have declared them in this consultation.

I understand that the decision to issue medication lies solely with the prescriber and that submission of this form does not guarantee that a prescription will be issued.

I agree to inform my regular GP of this consultation, any medication issued, and any relevant changes in my symptoms or medical condition.

I agree to seek medical advice from my GP or appropriate healthcare provider if my symptoms do not improve within 14 days, if they worsen at any time, or if I experience any unexpected side effects.

I understand that this service is not suitable for medical emergencies and that I should contact emergency services if I require urgent medical attention.

I confirm that I have read and agree to the i-Prescribe Terms and Conditions and Privacy Policy.

Confirmation*

I confirm the above

Consent*

I confirm the details are true and I consent to processing my health data.

Do you have an account?*

Yes

Create Account

Username*

Password*

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Benefit From Online Assessments

01

Benefit 1

Do it from the comfort of your home.

02

Benefit 2

No awkward face to face appointments

03

Benefit 3

You no longer have to wait for appointments

Need Support?

We want to make sure you get the treatment you need. If you need help completing this assessment, or prefer to complete an assessment over the phone, click below to call us.

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This assessment WILL TAKE approximately 3 minutes

Your Health Consultation

Medical Questions

Declaration and Consent

Create Account

Benefit From Online Assessments

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Benefit 1

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Benefit 2

03

Benefit 3

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