Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.About You - Step 1 of 4Name *FirstLastEmail *Date of birth *Contact Number *Please provide your weight *KgStone/PoundsLayoutDropdown *Stones07 st08 st9 st10 st11 st12 st13 st14 st15 st16 st17 st18 st19 st20 st21 st22 st23 st24 st25 st26 st27 st28 st29 st30 st31 st32 st33 st34 st35 st36 stDropdown *Weight (Kg)404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250Dropdown *Pounds00 lb01 lb2 lb3 lb4 lb5 lb6 lb7 lb8 lb9 lb10 lb11 lb12 lb13 lbPlease provide your height *Feet & InchesCentimetresLayoutDropdownFeet04 ft05 ft06 ft07 ftDropdown *Centimetres120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200DropdownInches00 in01 in02 in03 in04 in05 in06 in07 in08 in09 in10 in11 inDo you smoke or drink? *YesNoPlease provide details (i.e. How much do you smoke or drink?) *Do you take any of the following medications? (Please select all that apply) *Isosorbide mononitrate/dinitrateNicorandilGlyceryl Trinitrate spray/tabletsAny other nitrate containing medication?Saquinavir/ritonavirHIV treatmentsItraconazole/Ketoconazole/ErythromycinNoneDo you take any medication whether prescribed, over the counter, herbal/alternative or partake in any recreational drug use? *YesNoPlease provide details *Do you have any allergies? *YesNoPlease provide details *What is your blood pressure? *Normal (90/60mmHg to 140/90mmHgHigh (over 140/90mmHg)Low (below 90/60mmHg)Not sureHave you been advised to avoid strenuous exercise? *YesNoPlease provide details *Are you able to walk 3 miles or climb a set of stairs without pain in your chest? *YesNoPlease provide details *Do you have any history of symptoms of anxiety or depression? *YesNoPlease provide detailsNextDo you have trouble achieving or maintaining an erection? *YesNoHow long have you been suffering with erectile dysfunction? *6 months6 months - 2 years2 years+Over the last 6 months how would you rate your confidence to get and keep an erection? *Very lowLowModerateHighVery HighWhen you had erections with sexual stimulation, how often were they hard enough for penetration? *NoneAlmost neverA few timesSometimesMost timesAlwaysDuring sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? *NoneAlmost neverA few timesSometimesMost timesAlwaysDuring sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? *Did not attempt intercourseExtremely difficultVery difficultDifficultSlightly difficultNot difficultWhen you attempted sexual intercourse, how often was it satisfactory to you? *Did not attempt intercourseAlmost neverA few timesSometimesMost timesAlwaysHave you taken any treatment for erectile dysfunction before? (Viagra/sildenafil, Cialis/tadalafil, Levitra/vardenafil, caverject) *YesNoPlease provide further details *e.g. product, strength, when last taken and did it work?Is there anything else you feel we should know about prior to you taking this medication?NextWould you like us to inform your GP of your treatment? *YesNoWe recommend informing your GP surgery of any treatment that you are taking to keep your medical records relevant and up to dateDo you give us consent to write to your GP for approval of this supply and to share information we hold about you?NextDo you agree to the following? *YesNoYou have answered all of the above questions accurately and truthfully. You understand our prescriber(s) will prescribe medication based on your responses and interactions with Twilight Pharmacy. Any incorrect responses or deliberate acts to misinform may be hazardous to your health. You agree to the terms and conditions, privacy policy and terms of use. You will familiarise yourself with the patient information leaflet included with your order and any other information relayed to you via other means including IM/E-mail/telephone. You will contact us and inform your GP if you experience any side effects to treatment, if there are any changes to your medical history including starting any new medications or new diagnoses, or if your symptoms/medical conditions change in any way. You understand completing a purchase does not guarantee supply of treatment; the final decision to prescribe lies with the prescriber with your best interests, health and appropriateness in mind. You agree to the terms and conditions, privacy policy and terms of use. Submit
