Are you a male aged between 18 and 65?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Does suffering from premature ejaculation cause you personal distress or difficulties in your relationship with your partner?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you been previously diagnosed from premature ejaculation?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you ever been advised by your doctor not to have sexual intercourse for medical reasons?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

During sexual activity do you ejaculate in less than 2 minutes?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you been suffering from premature ejaculation for more than 6 months?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you drink alcohol?

Yes No

We can still prescribe you this medication, however please note that smoking and drinking alcohol can make your erectile dysfunction condition worse.

Have you ever had an allergic reaction from taking Priligy, Dapoxetine or from applying Emla (lidocaine, prilocaine) cream?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any of the following?

Yes No

Antiplatelet medication (warfarin, aspirin, clopidogrel);
cimetidine or beta blockers (bisoprolol, propranolol, atenolol);
nitrates (nicorandil, glyceryl trinirate, GTN spray, isosorbite mononitrate, isosorbite dinitrate) for chest pain;
Medicines to treat uneven heartbeat (amiodarone);
Antiepileptics (phenytoin or phenobarbital);
Alpha blockers (doxazosin, tamsulosin);
PDE5 inhibitors (sildenafil, tadalafil);
MAO inhibitors (tranylcypromine, moclobemide, selegiline);
Thioridazine;
Antidepressants (sertraline, citalopram, tramadol) ;
lithium;

Please specify which of the medicine(s) above you are taking and its dosage

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any other medication not mentioned in the question above?

Yes No

Please provide the name, dosage and the reason why you are taking that medication

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you suffer from any of the following?

Yes No

Low blood pressure (below 90/50) or high blood pressure;
Heart conditions (such as angina, chest pain, heart failure, irregular heartbeats, heart attack or narrowing of the aortic valve);
History of prostrate problems or prostate surgery;
Pain in your genitals, when you ejaculate or when you pass urine;
Glucose-6-dehydrogenase deficiency (blood disorder);
Bleeding or clotting disorders;
Epilepsy or seizures;
Parkinson‘s disease;
Depression;
Liver or kidney problems;
Any other chronic condition that we should know about;

Can you provide more details please?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you aware of the following?

Yes No

PRILIGY® can lower your blood pressure increasing the risk of falls;
while taking PRILIGY® you can experience syncope (temporary loss of consciousness usually related to insufficient blood flow to the brain) at any time with or without prodromal symptoms;
it is very important to maintain adequate hydration during taking PRILIGY®;
Should syncope or other central nervous effects occur you should avoid situations where injury could result, including driving or operating hazardous machinery;
You should not be using PRILIGY® with alcohol because this may increase the risk of accidental injury;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

The treatment is solely for your own use;
You have answered thrutfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health;
You will inform your doctor about any unusual side effects;
You will read the patient information leaflet supplied with your medication;
You will not exceed the maximum daily dose of the medication ;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

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I confirm that I am over 18 and I agree to the Terms and Conditions and the Privacy Policy.

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Medical Assessment