Viagra Online Consultation Form

This online form for Viagra Connect will save you time on your visit to Santry’s Pharmacy. If you request the pharmacist to call you, most of the consultation can occur by phone before you visit the store. Otherwise, the pharmacist will have your form ready and they will have a private consultation with you in the store. This takes a few minutes to complete.


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 experiencing erectile dysfunction?
Yes No

GENERAL HEALTH
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:
- 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
Yes No Unsure
OTHER INFORMATION
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 Unsure

Are you using drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)?
Yes No

Do you have Peyronies 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

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

What pack size do you require?
4 Pack 8 Pack



We usually respond within 24 hours.