Viagra Connect Online Consultation Form

For Repeat Customers

This form is for men over the age of 18 who have purchased Viagra Connect from internetpharmacy.ie before. The pharmacist will review the form before your purchase of Viagra Connect is dispatched. The pharmacist may need to phone you if they feel your answers on this form might mean that Viagra Connect is unsuitable for you. If you have not purchased Viagra Connect from this internet pharmacy store previously, then you should complete the New Customer form instead.


Name:

Phone:

Email:

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.

Are you a male over 18 years of age who is experiencing erectile dysfunction?

Have you purchased Viagra Connect from internetpharmacy.ie before ?

It would speed up your order if you could provide a previous order number - but it is not essential

Have any of your medicines changed since the last time you bought Viagra Connect from internetpharmacy.ie?

Has anything changed to your health since the last time you bought Viagra Connect from internetpharmacy.ie?

Select your choice of Viagra Connect