• Are you male and between the ages of 18 and 75?*
  • Do you have trouble achieving or maintaining your erection?*
  • Please tick if you have ever suffered from any of the following conditions:*
  • Do you currently suffer from any other conditions in general?*
  • Have you been advised to avoid strenuous exercise?*
  • Have you used Erectile Dysfunction medication before?*
  • Which Erectile Dysfunction medication have you tried?*
  • Are you taking any of the following medicines/ products?*
  • Other than treatments for ED or any of the treatments previously mentioned, do you currently take any other medicines or herbal preparations in general? (This includes treatments for unrelated conditions, treatments bought over the counter, inhalers, creams etc).*
  • Have you suffered any adverse reactions or side effects from any treatments or medicines in the past?*
  • Do you have any allergies to any food products/ medicines?*
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  • Please provide the following details so that our prescriber can write a private prescription which will be used to dispense and supply your medicine.

  • Are you currently registered with a GP?*
  • Please select your preferred means of contact from the options below. We need this in case we need to contact you about your order.*

  • Click on the links below to access the terms and conditions, and the privacy policy. Please ensure that you have read them carefully.

    Goodcure Pharmacy Terms and Conditions

    Goodcure Pharmacy Privacy Policy

  • Please tick to agree and confirm all of the following:*
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