Viagra connect - Laois Pharmacy

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Viagra Connect

Please fill out the form below...

Viagra Connect

- Step 1 of 4

Name *

First

Last

Date of Birth *

Are you experiencing erectile dysfunction? *

Yes
No

Viagra Connect is only intended for use in men who are experiencing erectile dysfunction (ED) i.e. difficulty in getting and/or maintaining an erection satisfactory for sexual performance.

Has your doctor advised that you are not fit enough for any physical and/or sexual activity? *

Yes
No

Do you feel very breathless or experience chest pain with light or moderate physical activity, such as walking briskly for 20 minutes or climbing two flights of stairs? *

Yes
No

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

Yes
No

Do you have any other heart problems or are you under a doctor’s care for any of the following listed below: *

Yes
No
Unsure

Low blood pressure or uncontrolled high blood pressure Unstable angina (chest pain), irregular heart beat or palpitations (arrhythmia) A problem with one of the valves in your heart (valvular heart disease) A problem where the heart muscle becomes inflamed and does not work as well as it should (cardiomyopathy) Heart problems causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure

If so, please list below:

Some men are on medication or have certain health conditions that could make Viagra Connect unsafe to take. The following questions help the pharmacist establish if Viagra Connect is suitable for you.

Are you taking any medication, including any other erectile dysfunction treatments? *

Yes
No

Please enter a full list of all regular medication on this form or bring a list with you when you come to the pharmacy.

If so, please list below:

Are you using drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)? *

Yes
No

Do you have Peyronie’s disease or any other deformation of the penis? *

Yes
No

Have you ever had loss of vision because of damage to the optic nerve (such as non-arteritic anterior ischaemic optic neuropathy [NAION]) or have an inherited eye disease (such as retinitis pigmentosa)? *

Yes
No

Do you have any other illnesses, medical conditions, or allergies? *

Yes
No

If so, please list below:

What pack size do you require? *

4 Pack
8 Pack

Contact Phone Number *

By entering your phone number here, you are consenting to the pharmacist contacting you by phone to carry out a consultation. (If you do not consent to being contacted and want to complete the consultation in store, please leave this question blank)

Confirm *

I understand that I should schedule a health check-up with my doctor as soon as I can within 6 months first receiving Viagra Connect to check for underlying medical problems that can sometimes be associated with erectile dysfunction.

Message

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