Viagra Connect Online Consultation Form
This form is for men over the age of 18 who have not purchased Viagra Connect from internetpharmacy.ie before. It takes 2 minutes to complete. 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 purchased Viagra Connect from this internet pharmacy store previously and there has been no change since then to your health or the medicines you take, then you should complete the Repeat Customer form instead
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?
Has your doctor advised that you are NOT fit enough for any physical and/or sexual activity?
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?
Have you had a heart attack or stroke within the last 6 months?
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
Are you taking any medication, including any other erectile dysfunction treatments?
If Yes, please list here:
Are you using drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)?
Do you have Peyronies disease or any other deformation of the penis?
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)?
Do you have any other illnesses, medical conditions, or allergies?
If yes, please list here
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.
Select your choice of Viagra Connect