Are you registered with a GP practice in the UK?

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you? (The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you.)

Do you believe you have the capacity to make decisions about your own healthcare?

Does premature ejaculation cause you personal distress or inter-personal difficulty with your partner?

Do you suffer any pain whilst ejaculating, or do you have any difficulty or pain passing urine?
(If yes please speak to your GP)

Does it take you less than 2 minutes to ejaculate after penetration?

Do you ejaculate before you want to?

Do you find it difficult to achieve or maintain an erection before ejaculation?

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

Have you ever had prostate surgery or been diagnosed with any conditions of the prostate?
(If yes please speak to your GP)

Are you allergic (hypersensitive) to Priligy or dapoxetine?

Do you have low blood pressure (below 90/50)?
If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Do you have a tendency to faint or get light-headed when you stand up from a lying position?

Do you smoke or drink alcohol?

Do you have any known allergies?

Have you ever suffered from any of the problems listed below?

• Mental health conditions such as depression, mania , bipolar disorder or schizophrenia
• Heart conditions (e.g. angina, chest pain, heart failure, irregular heart beats, heart attack or narrowing of any heart valve)
• A history of bleeding or blood clotting problems
• A history of glaucoma or have been told you are at increased risk of glaucoma due to family history raised intraocular pressure
• Kidney problems
• Prostate problems
• Epilepsy
• Recurrent Fainting
• Moderate or severe liver problems galactose intolerance, the Lapp lactase deficiency or glucose−galactose malabsorption
• Any serious medical condition which may require immediate hospitalisation

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Do you understand that if you feel light headed soon after standing, you should immediately  lie down so your head is lower than the rest of your body or sit down with your head between your knees until the symptoms pass? You should also ensure you do not rise too quickly after prolonged lying or sitting and do not drive or operate machinery if you experience these symptoms.

• I confirm I am over 18 years old.
• The medicine ordered is for my sole use only.
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
• I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
• You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.