Erectile Dysfunction (ED) Treatment – Sildenafil Suitability Assessment

  • Erectile Dysfunction (ED) Treatment – Sildenafil Suitability Assessment

    Sildenafil 25mg, 50mg, and 100mg tablets are prescription-only medicines for treating erectile dysfunction in adult men. Please answer all questions honestly; providing false information may put you at risk.
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  • Section 1: Patient Details

  • Next working day delivery available. Delivery charge of £2.50 will apply. 

  • Submit form by 12pm, and you qualify for FREE same day delivery

  • You qualify for FREE next day delivery

  • Would you prefer delivery or to collect from Balance Pharmacy, Balance Street, Uttoxeter, ST14 8JG*
  • Date of Birth*
     - -

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  • Format: 00000000000.
  • Which sildenafil strength are you seeking?*

  • Section 2: Eligibility Confirmation

  • Confirm you are male*
  • You have selected you are not male, this medication is only suitable for males.
  • Confirm you are 18 years of age or older*
  • Please ensure you are at least 18 years old to proceed with this assessment.
  • Do you consent to this assessment and understand this is a prescription-only medicine?*
  • Your consent is essential for us to proceed with this assessment and prescription process. Please read carefully before agreeing.

  • Section 3: Erectile Dysfunction History

  • Are you experiencing erectile dysfunction?*
  • How long have you had symptoms?

  • Section 4: Medical History

  • Medical History - Please select all that apply*
  • Have you used Sildenafil or other ED medication before?

  • Section 5: Current Medications

  • Current Medications/Drug Usage - Please select all that apply*

  • Section 6: Declaration

  • Date*
     - -

  • Clinician Section

  • Inclusion criteria met
  • Exclusion criteria present
  • Supply authorised?
  • Is this for same day delivery?
  • Delivery charge applicable?
  • Dose supplied
  • Date of supply
     - -
  • Should be Empty: