Viagra Connect Order Form
Slattery's Pharmacy

First Name *

Last Name *

Date of Birth *

Email Address *

Phone *

Address *

Eircode

County of Residence * Please, select Carlow Cavan Clare Cork Donegal Dublin Galway Kerry Kildare Kilkenny Laois Leitrim Limerick Longford Louth Mayo Meath Monaghan Offaly Roscommon Sligo Tipperary Waterford Westmeath Wexford Wicklow

Your GP's name and contact details *

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

Are You Taking Other Medications? *

Please list medications here

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)? *

Are you taking nitrates (nicorandil or other nitric oxide donors e.g. glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate) for chest pain? *

Are you taking riociguat or other guanylate cyclase stimulators for lung problems? *

Are you taking ritonavir (for HIV infection)? *

Are you taking any CYP3A4 inhibitors, e.g. saquinavir (to treat HIV infection), cimetidine (a heartburn treatment), itraconazole or ketoconazole (to treat fungal infections), erythromycin or rifampicin (antibiotics) or diltiazem (for high blood pressure)? *

Are you taking any alpha-blockers, such as alfuzosin, doxazosin or tamsulosin, which are medicines to treat urinary problems due to enlarged prostate (benign prostatic hyperplasia) or occasionally to treat high blood pressure? *

Do you have galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption? *

Do you have previously diagnosed hepatic (liver) disease (including cirrhosis of the liver) or severe renal (kidney) impairment? *

Do you have any of the following: sickle cell anaemia, multiple myeloma or leukaemia? *

Do you have any bleeding issues (e.g. haemophilia) or have active stomach ulcers? *

Do you suffer from any illnesses, conditions or allergies? *

Please list allergies here

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