Viagra Connect

Viagra Connect is an effective treatment for Erectile Dysfunction (ED) in men aged 18 years and older, It can be a warning sign of health condition or disease you might not be aware of. This could also put a strain on relationships.

 

Online form for Viagra Connect

Consultation can be done on phone before you visit the store.
Otherwise, the pharmacist will have your form ready and you can have a private consultation with you in the store.
This takes a few minutes to complete.

    Viagra Connect is only intended for use in men who are experiencing erectile dysfunction (ED) i.e. difficulty in getting and/or maintaining an erection satisfactory for sexual performance.

    Are you experiencing erectile dysfunction?
    Has your doctor advised that you are not fit enough for any physical and/or sexual activity?
    Do you feel very breathless or experience chest pain with light or moderate physical activity, such as walking briskly for 20 minutes or climbing two flights of stairs?
    Have you had a heart attack or stroke within the last 6 months?
    Do you have any other heart problems or are you under a doctor’s care for any of the following:
    • Low blood pressure or uncontrolled high blood pressure
    • Unstable angina (chest pain), irregular heart beat or palpitations (arrhythmia)
    • A problem with one of the valves in your heart (valvular heart disease)
    • A problem where the heart muscle becomes inflamed and does not work as well as it should (cardiomyopathy)
    • Heart problems causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure

    Some men are on medication or have certain health conditions that could make Viagra Connect unsafe to take. The following questions help the pharmacist establish if Viagra Connect is suitable for you.
    Are you taking any medication, including any other erectile dysfunction treatments?
    Please enter a full list of all regular medication on this form or bring a list with you when you come to the pharmacy.
    Are you using drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)?
    Do you have Peyronie’s disease or any other deformation of the penis?
    Have you ever had loss of vision because of damage to the optic nerve (such as non-arteritic anterior ischaemic optic neuropathy [NAION]) or have an inherited eye disease (such as retinitis pigmentosa)?
    Do you have any other illnesses, medical conditions, or allergies?
    I understand that I should schedule a health check-up with my doctor as soon as I can within 6 months first receiving Viagra Connect to check for underlying medical problems that can sometimes be associated with erectile dysfunction.
    What pack size do you require?

    NEXT STEP?
    We will review the information and prepare for your consultation. If you request a phone consultation by entering your phone number below the pharmacist will call you to carry out the consultation over the phone. Your medication will be ready for collection within 1 hour (during store opening hours). You will still need to come to the pharmacy yourself to collect the medication.

    CONTACT PHONE NUMBER
    By entering your phone number here you are consenting to the pharmacist contacting you by phone to carry out a consultation. (If you do not consent to being contacted and want to complete the consultation in store, please leave this question blank)

    By clicking submit, I confirm that the information I have given is correct to the best of my knowledge. I am aware that I will need to attend the pharmacy in person and to speak with the pharmacist before emergency contraception will be supplied. I am aware that the Pharmacies will retain this questionnaire for a period of two years in line with Data Protection Requirements