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AllCare Pharmacy | Simplifying Healthcare

About Us
Weight Loss
Period Delay
Travel Clinic
Other

About Us
Weight Loss
Period Delay
Travel Clinic
Other

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Premature Ejaculation

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Please enable JavaScript in your browser to complete this form.

Do you think you have premature ejaculation? *

Yes
No

Can you tell us why you require medication for premature ejaculation? *

How long have you been experiencing premature ejaculation? *

Ever since my first sexual encounter
For more than 6 months
For less than 6 months

How often do you feel affected by premature ejaculation? *

Every time I have sex
More than half the time
Less than half the time

Can you tell us more details about these occasions? *

How soon after entering your partner do you ejaculate? *

I ejaculate before entering my partner
Less than 2 minutes
Between 2 and 5 minutes
Between 5 and 10 minutes
More than 10 minutes

Do you think you have control of when you ejaculate? *

Yes
No

Why do you feel you have premature ejaculation? *

Does premature ejaculation cause distress or difficulties in your sex life? *

Yes
No

Please can you tell us how, or whether, it affects your sex life or relationships in any other way?

Have you tried any medication for premature ejaculation before? *

Yes
No

Can you tell us more details about what you have tried before? *

Can you always get and maintain an erection when you want one? *

Yes
No

Can you tell us more details about what you have tried before? *

Can you always get and maintain an erection when you want one? *

Yes
No

Your ejaculation symptoms might improve by trying erectile dysfunction treatments, like Viagra, first. You can order ED treatment here.

Do you have any heart conditions such as heart failure, ischaemic heart disease, heart valve problems, heart rhythm problems or peripheral vascular disease? *

Yes
No

Please provide more details. *

Do you have, or have you ever had, a condition such as mania, bipolar disorder or schizophrenia?

Yes
No

Please provide more details. *

Are you experiencing depression or anxiety, or are you currently taking antidepressant medications? *

Yes
No

Please provide more details. *

Do you have any neurological conditions such as epilepsy, or fainting episodes due to low blood pressure? *

Yes
No

Please provide more details. *

Do you have any blood clotting disorders or take any medication that affects your blood clotting? *

Yes
No

Please provide more details. *

Do you have any liver or kidney conditions? *

Yes
No

Please provide more details. *

Do you have any eye conditions such as glaucoma? *

Yes
No

Please provide more details. *

Do you have any prostate conditions such as prostatitis or benign prostatic hypertrophy? *

Yes
No

Please provide more details. *

Do you have any hormone conditions such as thyroid problems or hypogonadism (low testosterone levels)? *

Yes
No

Please provide more details. *

Do you have any other medical conditions not mentioned already? *

Yes
No

Please provide more details. *

Are you currently taking any medication, or have you recently finished a course of medication? *

Yes
No

Please list the names and doses of all these medications. *

What do you use these medications for? *

Are you allergic to any medicines or other substances? | For instance lactose. *

Yes
No

Please tick all of the allergies that apply to you. *

Penicillin
Peanuts or Soya
Lactose
Other medication
Other substance

Please provide more details

On average, how much alcohol do you drink per day? *

I never drink
1 pint of beer/2 small glasses of wine or less
More than 1 pint of beer/2 glasses of wine

alcohol *

It is important to know that drinking alcohol when using Priligy can cause serious side effects, so you should avoid alcohol when using Priligy. Please tick to confirm that you understand this

Have you taken any illegal drugs or 'legal highs' in the last 6 months? *

Yes
No

drugs *

Using certain recreational drugs including MDMA, LSD, ecstasy and sedatives with Priligy can cause serious side effects. You should not use Priligy if you have used any recreational drugs. Please tick to confirm that you understand

Checkboxes *

I fully understand the questions asked and have answered honestly & truthfully. I fully understand the side-effects of the treatment options, their effectiveness and alternative options & am happy to continue with my request. I confirm & agree that any treatment prescribed for me is for my personal use only. *
Please tick here to signify that you have read, understand and agree to abide by our Privacy Policy. *

Your request *

PRILIGY30mg (3 tablets)
PRILIGY30mg (6 tablets)
PRILIGY30mg (12 tablets)
Telephone Consultation with a Doctor (does not include prescription medication): (Only Phone consultation)

What’s Your Birth Gender? *

Male
Female

Name *

First

Last

Email *

Phone *

What’s Your Date of Birth? *

us are out

Select pharmacy for collection *

674 Coventry Road, Small Heath, Birmingham, B10 0UU
105 Barton Street , Gloucester, GL1 4HR
267 Dewsbury Road, Leeds, LS11 5HZ
41 Caldmore Green, Walsall, West Midlands, Walsall, WS1 3RW

Nationwide Delivery

Yes

Do you agree and consent to the following? You are completing this consultation for yourself and to the best of your knowledge. You will disclose any medical conditions, serious illnesses or operations you have had. You will disclose any prescription medications you are currently taking and agree to use only use one weight loss treatment at a time. You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy. Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life- threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation. *

Please confirm you understand

Privacy Policy *

I have read, understand and agree to AllCare Pharmacy Online Doctor's Privacy Policy

Birmingham

0121 772 3108
674 Coventry Road, Small Heath, Birmingham,
B10 0UU

Gloucester

01452 546 534
105 Barton Street , Gloucester,
GL1 4HR

Leeds

0113 276 2954
267 Dewsbury Road,
Leeds,
LS11 5HZ

Walsall

01922 626626
41 Caldmore Green, Walsall,
West Midlands, Walsall,
WS1 3RW

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