Erectile Dysfunction Treatment

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ORDER SUMMARY
Total costEUR
Prescription ConsultationOnline Consultation Fee
€25.00Edit
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Total cost €0.00
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Last Name
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I confirm that I am 18 years of age or older, using this service voluntarily and on my own behalf. Any treatment or advice provided is intended solely for my personal use.* This field is required.
Agree
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3
partner
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Burkes Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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Havens Pharmacy Macroom
Carrigtwohill Pharmacy
I prefer sending to another pharmacy
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McGorisks Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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McGorisks Pharmacy, The Crescent
McGorisks Pharmacy, Clonbrusk
McGorisk's Pharmacy, Ballinasloe
McGorisks Pharmacy, Athlone
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Tom Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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Molloy Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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Molloys Pharmacy - Garden Street, Ballina, F26 W951
Molloys Pharmacy - Bunree Road, Ballina, F26 Y9PF
Molloys Pharmacy - Main Street, Crossmolina, F26A4E3
Molloys Pharmacy - The Harrison Centre, Roscommon, F42 H002
Molloys Pharmacy - Ballaghaderreen, Co. Roscommon, F45X896
Molloys Pharmacy - Knocknacarra, Co. Galway, H91VPX2
Molloys Pharmacy - Davitt Quarter, Achill Island, F28V4P0
Molloys Pharmacy - Claremorris, F12RX02
I prefer sending to another pharmacy
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Scanlon Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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SCANLONS PHARMACY, ENNIS RD BRANCH
SCANLONS EXPRESS LATE NIGHT PHARMACY, DOCK ROAD
SCANLONS PHARMACY, CASTLETROY BRANCH
LIMITLESS HEALTH PHARMACY
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Full Pharmacy Name and Address is Required* This field is required.If Successful Your Script will be sent to this pharmacy.
If you do not provide correct details your application may be denied.
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Name* This field is required.
First Name
Last Name
11
Email* This field is required.
example@example.com
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Address* This field is required.
Street Address
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Country
13
Date of Birth* This field is required.
Date
Day
Month
Year
14
Phone Number* This field is required.
Area Code
Phone Number
15
Please specify which of the following medicationa that you would like to get prescription for?* This field is required.
Viagra
Cialis
Levitra
Spedra
Sildenafil Clonmel (Generic Viagra)
16
Please specify the dose of medication from the list below, if you dont know, please select 'Don't Know'* This field is required.
Don't know
2.5mg
5mg
10mg
20mg
17
Are you allergic to any medication?* This field is required.
YESNO
18
You have selected YES, please specify
Huge
Large
Normal
Small
Ok
Ok
19
Have you ever used this ED treatment previously?* This field is required.
YESNO
20
Have you ever been prescribed ED treatment before?
YESNO
21
When was the last time you got your blood pressure checked?* This field is required.
Less than 6 months ago
More than 6 months ago
Never
22
Please specify below if you remember the last blood pressure reading? (eg: 120/80 mmHg)
23
Do you have any past medical history or any past surgical history that you want to mention to our doctor?
YESNO
24
You have selected YES, please specify
25
When did you first experience your ED?* This field is required.
LESS THAN 12 MONTHS AGO
MORE THAN 12 MONTHS AGO
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Did you develop ED symptoms gradually or suddenly?* This field is required.
SUDDENLY
GRADUALLY
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In regards to your erection, would you define it as fully stiff or soft?* This field is required.
SOFT
STIFF
Other
28
You have selected "Other" please specify further
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During sexual intercourse is your erection sufficient enough for you to manage penetration?* This field is required.
YES, I WAS ABLE TO PENETRATE
NO, I COULD NOT PENETRATE
Other
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You have selected "Other" please specify further
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Does your erection go soft during sexual intercourse and inhibit your ability to penetrate?* This field is required.
YESNO
32
Do you get morning erection ? (notice an erection upon wakening)?* This field is required.
Most Mornings
1 - 2 Per Week
1 - 2 Per Month
Less Frequently
Not Anymore
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Do you have normal ejaculation when you masturbate?* This field is required.
YESNO
34
Have you ever been diagnosed with psychological or psychiatric issues (for example anxiety, panic attacks or depression, mania, bipolar disorder or schizophrenia)?* This field is required.
YESNO
35
You have selected YES please specify further
36
Is your ED impacting your relationship?* This field is required.
Yes
No
Not in a relationship
37
Do you exercise regularly?
YESNO
38
Do you smoke cigarettes?* This field is required.
No I don't Smoke
Yes, Less than 5 per week
Yes, Less than 10 per week
Yes, Less than 5 per day
Yes, Less than 10 per day
Yes, Less than 15 per day
Yes, Less than 20 per day
Yes, more than 20 per day
39
Do you drink alcohol?* This field is required.
No, I do not drink alcohol
Yes, 0-10 units weekly
Yes, 11-20 units weekly
Yes, 21-30 units weekly
Yes 30+ units per week
40
Are you currently taking any prescription, non prescription or illegal drug or herbal medication and have you recently taken any medication in the last two weeks?* This field is required.
Yes
No
41
You have selected YES please specify further
42
Attach a File/Photo of Your Regular Medications/Script (Optional)
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Select files to upload
Max. file size: 10.6MB
Cancelof
43
Declaration of consent.* This field is required.
I understand the mentioned questions and I have answered them truthfully and to the best of my knowledge.
44
Script Application
Please Select
Please Select
Approved
Not Approved
Script Application
45
GDPR Consent Form* This field is required.To assist with your care, we at Dooctor.ie need to collect personal data about you. This information will include details of your health and your treatments. We may also need to record additional information that while may not seem to relate directly to your health it would help in our treatment of you. Examples of this kind of information would include things like your age, gender, marital status, number of children you have, your nationality, your employment status, religion, prison sentences. Our policy is only to collect and record information about you that helps in your treatment. Declaration  I understand my health information will be seen or shared only with medical and administrative staff involved in my care or where Dooctor.ie is required to do so by law.  I understand that for the purposes of my treatment administrative staff may have to access my health data. Reasons for this access would include the re-issuance of prescriptions, the opening of letters and recording of information from hospitals about me, downloading and saving in my file results from laboratories, typing of letters to hospitals and other similar health related issues.  I understand that all Dooctor.ie staff sign a confidentiality agreement that binds them not to disclose my details to any unauthorised persons not involved in my care.  I understand that any health data shared outside of the practice for the purposes of my health treatment will, normally, be limited to information related to a particular treatment and not my entire file.  I understand that my health data will be stored primarily on a secure database operated by a specialist company called Clanwilliam Health and I understand that Clanwilliam Health are only allowed process my health data under Dooctor.ie instructions.  I understand the law provides that in certain instances personal health information can be disclosed, e.g. in the case of some infectious diseases.  I understand that Dooctor.ie will only release information to, for instance solicitors or insurance companies, at my express request.  I understand that I can withdraw consent for processing of my personal health data at any time.
I confirm my consent.
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