Premature Ejaculation


Before we are able to prescribe any medication to treat your Erectile Dysfunction, we are going to ask you some questions to ensure it is safe and appropriate for us to issue a prescription. The answers to these questions are reviewed by a prescribing clinician who will then authorise the treatment. Before proceeding to these questions, please tick the boxes below to consent the following:

  • You were assigned male at birth and are currently over 18 years of age

  • You are experiencing some form of Premature Ejaculation

  • The treatment prescribed will only be taken by yourself

  • You will alert us to any serious conditions you may have and/or any procedures performed on yourself

  • You will alert us to any prescription medication you are taking

  • You will talk to your GP if you are a younger male (<30 years old) and suffer with depressive disorder (as this medication may cause suicidal ideation)

  • You agree to our terms and conditions

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How old are you?
When did you first notice you suffered with premature ejaculation?
How often do you suffer with premature ejaculation?
How soon after engaging in sexual activity do you ejaculate?
Do you have control over when you ejaculate?
Is your premature ejaculation causing you psychological stress?
Are you able to get and maintain an erection
Do you suffer with any of the following? (select all that apply)
Are you taking any of the following medications?
Is there anything else you feel we should know in order to ensure it is safe for us to prescribe our treatments? For example other health conditions, medication that you are taking, procedures you have had.
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Full Name
Date of Birth
Email Address
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