Consultation - MedsDoctor

1 About Your Health

Do you confirm that the requested medicine will be solely for your own use?

Yes

Do you have any known allergies? (medication or other substances)

Do you have any medical conditions?

Are you currently taking any medication?

Prescription, over-the-counter, supplements or recreational drugs

Do you smoke?

How much alcohol do you drink?

I do not drink alcohol

I drink less than 14 units per week

I drink more than 14 units per week

3 The Agreement and Consent

Please read the Agreement and Consent statements carefully during your consultation. They contain important information to help you stay informed and safe throughout your treatment.

Understanding of Risks

I understand that dapoxetine does not treat erectile dysfunction and should not be taken with erectile dysfunction medicines due to the risk of low blood pressure.

I understand that if I experience serious side effects, such as mood changes or seizures, I must stop treatment immediately and seek urgent medical help.

I understand that dapoxetine may cause dizziness or light-headedness on standing and that I should sit or lie down until this passes, avoid standing up quickly, and not drive or operate machinery if affected by any drowsiness or dizziness.

Medical Guidance

I agree to consult with my healthcare provider before starting any new medication.

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

I understand Dapoxetine is taken 1–3 hours before sexual activity, not more than once in 24 hours.

I understand Dapoxetine is not for daily use.

I understand Dapoxetine can cause dizziness, fainting, nausea, headache, and low blood pressure.

I agree to avoid alcohol when taking Dapoxetine

Consent to Share Information

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for the purpose of this assessment.

I consent to MedsDoctor Pharmacy contacting my GP if necessary.

I understand that MedsDoctor Pharmacy will inform my GP about treatment supplied.

Confirmation

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.

Assessment for Premature Ejaculation

Premature Ejaculation

1 About Your Health

Do you confirm that the requested medicine will be solely for your own use?

Do you have any known allergies? (medication or other substances)

Yes

Do you have any medical conditions?

Yes

Are you currently taking any medication?

Yes

Do you smoke?

Yes

How much alcohol do you drink?

2 About Your Condition

Do you usually ejaculate within about 1–2 minutes of penetration, with little control, and does this cause you distress or difficulty in your relationship?

Are you experiencing any other symptoms? Or noticed any triggers?

Yes

Have you been experiencing premature ejaculation for at least 6 months?

How often do you experience premature ejaculation symptoms?

Do you suffer from any of the following? (Please select all that apply)

Have you been prescribed medication for premature ejaculation before?

Yes

Are you currently taking any medication for premature ejaculation?

Yes

Have you experienced any side effects from your current or past premature ejaculation medications?

Yes

Do you suffer from or have you ever suffered from any mental health condition?

Yes

Do you suffer from or have you ever suffered from any heart condition?

Yes

Do you suffer from or have you ever suffered from any of the following?

3 The Agreement and Consent

Understanding of Risks

Medical Guidance

Consent to Share Information

Confirmation

Assessment Progress

Help Support

Assessment for Premature Ejaculation

Premature Ejaculation

1 About Your Health

Do you confirm that the requested medicine will be solely for your own use?

Do you have any known allergies? (medication or other substances)

Yes

Do you have any medical conditions?

Yes

Are you currently taking any medication?

Yes

Do you smoke?

Yes

How much alcohol do you drink?

2 About Your Condition

Do you usually ejaculate within about 1–2 minutes of penetration, with little control, and does this cause you distress or difficulty in your relationship?

Are you experiencing any other symptoms? Or noticed any triggers?

Yes

Have you been experiencing premature ejaculation for at least 6 months?

How often do you experience premature ejaculation symptoms?

Do you suffer from any of the following? (Please select all that apply)

Have you been prescribed medication for premature ejaculation before?

Yes

Are you currently taking any medication for premature ejaculation?

Yes

Have you experienced any side effects from your current or past premature ejaculation medications?

Yes

Do you suffer from or have you ever suffered from any mental health condition?

Yes

Do you suffer from or have you ever suffered from any heart condition?

Yes

Do you suffer from or have you ever suffered from any of the following?

3 The Agreement and Consent

Understanding of Risks

Medical Guidance

Consent to Share Information

Confirmation

Assessment Progress

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