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Viagra Connect Consultation Form
This online form for Viagra Connect will save you time on your visit to our Pharmacy. If you request the pharmacist to call you, most of the consultation can occur by phone before you visit the store. Otherwise we will have your form ready and have a quick and private consultation with you in the store.
Your Full Name *
Date of Birth *
Viagra connect is only for men aged 18+ with ED
Choose a store: *
Are you experiencing erectile dysfunction? *
General Health
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.
Other information:
Some men are taking medication or have certain health conditions that could make Viagra Connect unsafe to take. The following questions help our pharmacist establish if Viagra Connect is suitable for you.
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 Peyronie’s 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: *
What pack size would you like? *
Contact phone number
By entering your phone number here, you are consenting to our Pharmacist contacting you by phone to carry out a consultation. (If you do not consent to being contacted and would prefer to complete the consultation in store, please leave this box blank)
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. *
I confirm that the information I have given is correct to the best of my knowledge. I am aware that I will need to attend the Pharmacy in person and to speak with the pharmacist before Viagra Connect will be supplied. Higgins Pharmacies will retain the data provided above for one week in preparation for your consultation. Anonymised data will be retained for up to two years. *
* Denotes required field
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