Consultation - menhancements

Online Consultation

Please answer all questions honestly and completely so our health professional can ensure suitability and prevent any delays in supplying your medication

Full Name

Date Of Birth

Phone Number

Are you purchasing this medication for yourself?

Are you over 18?

Do you have symptoms of Erectile Dysfunction (i.e. difficulty getting or maintaining an erection)

Have you been instructed by your doctor to avoid sexual or physical activity?

Do you have a hereditary intolerance to galactose, lapp lactase deficiency or glucose-galactose malabsorption.

Do you have any allergies?

If Yes, Please specify any allergies

Have you had a heart attack or stroke within the last 6 months?

Do you suffer from or ever suffered from any of the following?

- Low blood pressure or uncontrolled high blood pressure
- Severe cardiac disorders such as unstable angina and severe cardiac failure
- Left ventricular outflow obstruction (e.g., aortic stenosis, hypertrophic obstructive cardiomyopathy or idiopathic hypertrophic subaortic stenosis)
- Exercise-induced ventricular tachycardia, implanted internal cardioverter defibrillator with frequent shocks, and poorly controlled atrial fibrillation Aortic and mitral valve disease, pericardial constriction, restrictive or congestive cardiomyopathy, significant left ventricular dysfunction, symptomatic coronary artery disease, Pulmonary veno-occlusive disease
-Heart failure

If Yes, Please specify

Do you have any other heart conditions?

If Yes, Please specify

Do you suffer from any of the following medical conditions?

- Previously diagnosed severe kidney disease, impairment or if you have been told your eGFR < 30mL/minute/1.73m2
-Previously diagnosed liver disease or impairment
- Sickle Cell Anaemia, Leukaemia or Multiple Myeloma
- An active stomach ulcer (if it is not active then tick no)
- A deformity to the penis such as Peyronie’s Disease
- Loss of vision due to non-arteritic anterior ischaemic optic neuropathy (NAION) as known hereditary degenerative retinal disorders
- Allergy, intolerance or hypersensitivity to sildenafil, tadalafil, vardenafil or avanafil.

If Yes, Please specify

Do you take any of the following medication?

- Alpha Blockers (Doxazosin, Alfuzosin, Prazosin, Tamsulosin, Indoramin or Terazosin)
- HIV Protease Inhibitors (Atazanavir, darunavir, fosamprenavir, lopinavir, ritonavir, saquinavir, tipranavir, atazanavir, clarithromycin, nefazodone, nelfinavir, telithromycin)
- Antifungals (Itraconazole, Ketoconazole, Isavucanazole, posacanzole or Voriconazole)
- Antiepileptics (Carbemazepine, Fosphenytoin, Phenobarbitol, Phenytoin, Primidone)
- Calcium Channel Blocker (diltiazam or verapamil)
- Netupitant, Imatinib, Idelalisib, Enazlutamide, Crizotinib, Cobistat, Arpitant, Dronaderone, Nilotinib, Rifampicin, Riociguat
- Any medication or drugs known to prolong the QT interval such as antidepressants (i.e. amitriptyline, citalopram/escitalopram, clomipramine, dosulepin, doxepin, imipramine, lofepramine), antiarrhythmics (ie. Quinidine, disopyramide, procainamide, amiodarone, sotalol, flecainide) antipsychotics (i.e. risperidone, haloperidol, chlorpromazine, quetiapine, clozapine), antimicrobials (i.e. erythromycin, clarithromycin, moxifloxacin, fluconazole, ketoconazole) antiemetics (domperidone, ondansetron).

If Yes, Please specify

Do you take any nitrates, including amyl nitrate (poppers), or nitric acid donors such as nicorandil, glyceryl trinitrate, isosorbide mononitrate and isosorbide dinitrate?

Do you take any recreational drugs?

If Yes, Please specify

Do you take any other medication or have any other medical conditions?

Please list all medications you take and medical conditions you have

Have you tried any treatments for Erectile Dysfunction Before?

If Yes, Please specify

Do you smoke?

Do you drink alcohol?

Are you overweight?

I agree that

- All questions have been answered to the best of my knowledge.
- I understand that I should regularly have my blood pressure, glucose and cholesterol levels checked with my GP.
- I am happy for pharmacists to review my consultation and prescribe the item requested if it is clinically suitable for myself.
- I understand my treatment request may be rejected due to clinical or other reasons. The treatment is solely for my own use and not for the use of others.
- I consent for Secret Potions Limited to undertake an ID check to confirm my age and identity. (This will be done using a credit check agency, no record will be put on your credit rating).
- Menhancements will not inform my GP of this consultation, unless specifically requested via emailing info@menhancements.com (please include GP name, address, and email address)
- If you have used the requested medication before, you confirm it is working as intended.

By agreeing to the above, you'll be directed to the next page to complete your medication purchase

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