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Weight Loss
- Weight Loss Service in Southall and Hillingdon
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Erectiles Dysfunction

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Let’s find the right treatment for you

Have you had an ED prescription with us?

Have you had an ED prescription with us?*

Yes

Do you agree and consent to the following?

I was assigned male at birth and I'm having difficulty getting or maintaining an erection.
I'm truthfully answering these questions for myself, and I understand that providing false information could lead to harm or even death.
I'll only use treatment as directed by my prescribing clinician, and I'll disclose any medical conditions I have and medication I take.
I accept the Terms & Conditions and Terms of Sale.

Let’s help you find the right treatment*

I'd prefer to plan ahead before sex and take a tablet 1 to 4 hours before intercourse

I'd like to be able to have spontaneous sex

Please tell us your age*

Under 18

18 to 25

26 to 69

70 or over

Your safety is our highest priority.

We regret that we are unable to provide you with ED medication.

Based on the responses provided in this consultation, we cannot recommend any of our treatments at this time.

Think you made an error? Giving inaccurate information can pose significant risks to your health.

Select all the following statements that apply to you*

I have never had an erection

I have been diagnosed with a cardiovascular disease (e.g. cardiomyopathy)

I have been able to maintain an erection in the past, but now I cannot reliably maintain an erection.

Your safety is our highest priority.

We regret that we are unable to provide you with ED medication.

Based on the responses provided in this consultation, we cannot recommend any of our treatments at this time.

Think you made an error? Giving inaccurate information can pose significant risks to your health.

Are you allergic to any of the following?*

Sildenafil (Viagra)

Tadalafil (Cialis)

Vardenafil (Levitra)

Avanafil (Spedra)

I am allergic to lactose or have a lactose intolerance

Not allergic?*

I am not allergic to any of the above

Your safety is our highest priority.

We regret that we are unable to provide you with ED medication.

Based on the responses provided in this consultation, we cannot recommend any of our treatments at this time.

Think you made an error? Giving inaccurate information can pose significant risks to your health.

ED medication can contain very small amounts of lactose. If you have taken a tablet formulation before without experiencing symptoms, it is unlikely that you will get undesirable effects from the lactose within our tablets.*

I can't tolerate any amount of lactose

I can tolerate very small amounts of lactose

What is your weight?

Weight (kg)*

Weight (St)*

Weight (Lbs)*

Weight metrics*

st/lbs

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Untitled

What is your height?

Height (cm)

Height (ft)

Height (in)

Height metrics*

ft/in

This field is hidden when viewing the form

Untitled

Select all the following statements that apply to you.*

I have been advised to refrain from strenuous activity, such as sex

I get chest pain or short of breath walking short distances, or up a flight of stairs

I have had a heart attack / myocardial infraction or stroke / transient ischaemic attack (TIA) in the last 6 months

I have a liver or kidney impairment

I am awaiting an organ transplant

I suffer from a hereditary degenerative retinal disorder

I have a history of non-arteritic anterior ischaemic optic neuropathy

My doctor informed me that I have high or low blood pressure

My doctor informed me that I have an irregular heartbeat

I suffer from any of the following: sickle cell anaemia, myeloma or leukaemia

I suffer from penile deformity, angulation, or have been diagnosed with Peyronie's disease

None of the above

Your safety is our top priority.

Unfortunately, we can’t offer you any ED medication.

Based on the answers given in this consultation, we cannot recommend any of our treatments to you.

Did you make a mistake? Providing false information can lead to serious harm to your health.

Have you been diagnosed with unstable angina or heart failure?*

Yes

Please tell us more about your chest pain or shortness of breath, including:

what happens when you experience it
if you’ve consulted a doctor about it
what the outcome of that consultation

Please also let us know if you’ve received any treatment or medications for your chest pain or shortness of breath.*

Please tell us more about your liver or kidney impairment, as well as the results of your most recent liver and/or kidney test.*

Please give us more information about your pending organ transplant, including the reason for your transplant and any treatments or medications you have received both in hospital and out of hospital.*

Please tell us more about your hereditary degenerative retinal disorder, please include the specific diagnosis and any treatment or medication you receive for your hereditary retinal disorder.

Have you had your blood pressure checked in the past 6 months?*

Yes

What was your blood pressure?*

Less than 90/50 mmHg (low)

Between 90/50 and 140/90 mmHg (normal)

Over 140/90 mmHg (high)

Do you take any medication for your blood pressure?*

Yes

What medication do you take for your blood pressure?*

Are you still experiencing any symptoms of irregular heartbeat, such as palpitations, or shortness of breath?*

Yes

Please tell us more about your irregular heartbeat, including your specific diagnosis (e.g. atrial fibrillation, cardiac arrhythmia), and any treatment or medication you receive for your irregular heartbeat.*

Sickle cell anaemia, multiple myeloma and leukaemia may predispose to priapism (a prolonged erection)*

I accept the risk that sickle cell anaemia, multiple myeloma and leukaemia may predispose to priapism (a prolonged erection) and would like to proceed

I do not accept the risk and do not wish to proceed

Which of the three conditions (sickle cell anaemia, myeloma or leukaemia) do you have? Please tell us more about your condition including any treatments or medications you receive for your condition.*

Please tell us more about your penile deformity, angulation or Peyronie’s disease including:

if you’ve seen a doctor about it
if you’re taking any treatment or medications for it
if it interferes with your ability to get an erection or ability to have sexual intercourse

Please tell us more about your penile deformity, angulation or Peyronie’s disease including:*

Your safety is our top priority.

Unfortunately, we can’t offer you any ED medication.

Based on the answers given in this consultation, we cannot recommend any of our treatments to you.

Did you make a mistake? Providing false information can lead to serious harm to your health.

Do you take any of the following medications or recreational drugs?*

Nicorandil, glyceryl trinitrate (GTN) spray, isosorbide mononitrate (ISMN) / dinitrate, amyl nitrate (poppers)

Cimetidine, indoramin, erythromycin / clarithromycin, fluconazole / itraconazole, ketoconazole, miconazole, voriconazole

Citalopram / escitalopram

Rifampicin, indinavir, tipranavir, atazanavir, darunavir, fosamprenavir, saquinavir

Doxazosin / tamsulosin / alfuzosin / terazosin / prazosin

Diltiazem, verapamil, amiodarone

Nilotinib, lapatinib, pazopanib, sunitinib

None of the above

Your safety is our top priority.

Unfortunately, we can’t offer you any ED medication.

Based on the answers given in this consultation, we cannot recommend any of our treatments to you.

Did you make a mistake? Providing false information can lead to serious harm to your health.

Please tell us which of these medications you take and what condition you are using it to treat.*

Is the dose of the medications being reviewed by your doctor, or has your dose been changed by your doctor in the last 1 month?*

Yes

Please tell us which medications you take and what condition you are using it to treat.*

Your safety is our top priority.

Unfortunately, we can’t offer you any ED medication.

Based on the answers given in this consultation, we cannot recommend any of our treatments to you.

Did you make a mistake? Providing false information can lead to serious harm to your health.

Have you taken, or are you currently taking any of the following erectile dysfunction treatments?*

Viagra sildenafil

Cialis tadalafil

Levitra / vardenafil

Spedra avanafil

Penile pumps

Penile injections (Caverject / Edex / Prostin VR)

Herbal / Ayurvedic remedies

Other

None of the above

What was the highest dose of Viagra/sildenafil that you took?*

Viagra / Sildenafil 25mg tablets

Viagra / Viagra Connect / Sildenafil 50mg tablets

Viagra / Sildenafil 100mg tablets

Did meet your expectations?*

Yes

Why did not meet your expectations?*

It wasn't effective

I experienced side-effects

I didn't like having to plan for sex

40% of men find the right ED treatment after testing multiple options*.

How long did you take for?*

Less than a month

1-6 months

Longer than 6 months

How many doses did you take?*

2-3

More than 3

What was the highest dose of Cialis/tadalafil that you took?*

Cialis / Tadalafil 2.5mg tablets

Cialis / Tadalafil 5mg tablets

Cialis / Tadalafil 10mg tablets

Cialis / Tadalafil 20mg tablets

Did meet your expectations?*

Yes

Why did not meet your expectations?*

It wasn't effective

I experienced side-effects

I didn't like having to plan for sex

**40% of men find the right ED treatment after testing multiple options*.**

How long did you take for?*

Less than a month

1-6 months

Longer than 6 months

How many doses did you take?*

2-3

More than 3

Did Levitra/vardenafil meet your expectations?*

Yes

Why did Levitra/vardenafil not meet your expectations?*

It wasn't effective

I experienced side-effects

I didn't like having to plan for sex

**40% of men find the right ED treatment after testing multiple options*.**

How long did you take Levitra/vardenafil for?*

Less than a month

1-6 months

Longer than 6 months

How many doses did you take?*

2-3

More than 3

Did Spedra/avanafil meet your expectations?*

Yes

Why did Spedra/avanafil not meet your expectations?*

It wasn't effective

I experienced side-effects

I didn't like having to plan for sex

**40% of men find the right ED treatment after testing multiple options*.**

How long did you take Spedra/avanafil for?*

Less than a month

1-6 months

Longer than 6 months

How many doses did you take?*

2-3

More than 3

Please tell us more about your experience with penile pumps, including how long you’ve used them and how effective they’ve been for you.*

Please tell us more about your experience with penile injections, including how long you’ve used them and how effective they’ve been for you.*

Please tell us more about your experience with herbal/Ayurvedic remedies, including how long you’ve used them and how effective they’ve been for you.*

Please tell us more about the erectile dysfunction treatments you’ve tried, including how long you’ve used them and how effective they’ve been for you.*

It's really important to tell us about:

Major illnesses
Ongoing medical conditions
Any medication prescribed or over the counter that you take
Allergies to medication
Operations

This information is needed so that our clinicians can ensure the prescription is safe for you to take.*

I have a major illness, ongoing medical condition, operation, allergy to medication or take prescribed or over the counter medication to tell you about.

I do not have a major illness, ongoing medical condition, operation, allergy to medication or take prescribed or over the counter medication to tell you about.

Would you like your GP to be informed of this consultation?*

To ensure we provide the best and safest service for you, we strongly encourage you to share your GP details so we can inform them about your treatment. If you are aware of your GP practice's email address, please enter them on the next screen.

Yes

Would you like your GP to be informed of this consultation?*

Yes

Please enter your GP's email address

GP's email address*

Get access to special offers

Take the first step towards improving your sexual health. You'll receive personalised health insights and exclusive monthly offers available only to Numan members.

Email address (optional)*

Please tell us about your major illness, ongoing medical condition, repeat medication, allergy, or operation you've had. This information is needed so that our clinicians can ensure the prescription is safe for you to take.*

Name

This field is for validation purposes and should be left unchanged.

Located in the heart of Southall and Hillingdon, our family-owned Independent Pharmacy has been serving the community for over 40 years.

Southall GPhc 1035128
Hillingdon GPhc 1035180

Hillingdon

Phone: 01895 272571

Email: puri.pharmacy@nhs.net

Southall

Phone: 0208 574 6848

Email: purichemist@nhs.net

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Pharmacy First in Southall and Hillingdon
Repeat Prescriptions
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Private Medical Cannabis in Southall and Hillingdon
Free NHS Blood Pressure Checks in Southall and Hillingdon
NHS Stop Smoking Service in Southall and Hillingdon

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