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♂ Patient - Erectile Dysfunction Treatment

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Which medication are you looking to get a prescription for? *

Please indicate what dose for the list below, if you are unsure, please select 'Don't Know' *

Do you have any allergies that you know of? *

Have you used your requested ED treatment previously? *

What age are you? *

Have you been prescribed a medication for ED by your GP previously? *

When was your blood pressure taken last? *

If you can remember your last blood pressure result, please enter below (eg: 120/80 mmHg)

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? *