Viagra Connect

TM

Available without Prescription

Erectile Dysfunction (ED) is a common condition, especially in men over 40, affecting the ability to achieve or maintain a firm erection. VIAGRA connect helps by increasing blood flow to the penis for satisfactory sexual experiences. It requires sexual arousal to be effective.

We appreciate your requirements for privacy and confidentiality, whilst ensuring your medications are obtained from a Trusted and reputable Community Based Pharmacy.

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Viagra-Connect Request Form

First Name

Date of Birth

Last Name

Suitability Checklist Evaluation *

I am an adult male, over 18 years, experiencing erectile dysfunction. The medicaton is for me. The doctor has advised me that I a fit to engage in physical activity. I do not suffer with breathlessness or experience any chest pain after light or moderate physical activity. I have not had a heart attack or stroke in the last 6 months. I do not use recreational drugs such a 'poppers' also known as amyl nitrite. I do not have a condition known as Peyronie's disease or any deformaton of the penis. I do not have any vision loss due to damage to my otic nerve or any inherited eye diseases. I am not allegic to Sildenafil, or any of the ingredients of this medicine.

I do not suffer from heart problems. I do not take any other medications includin treatments for erectile dysfuncton and I do not have any other medical conditions

If you have any medical conditions the pharmacist should be aware of, please list below

I have read and accept the privacy policy

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