Choose your Location

What is your date of birth?

How often are you suffering from erectile dysfunction?

Every timeHalf the timeOn occasionRarely

Have you had a physical exam with a healthcare provider in the past 3 years that included an examination of your genitals?

Yes, and it was normalYes, but there were issuesNo, I haven’t had a physical exam in the past 3 years

Have you ever been prescribed medications, vitamins or supplements to treat it before?

NoYes, the medication worked for meYes, but the medication didn't work for meI have tried multiple types of medication

Tell us more about the drug, including its name, dose, and any adverse effects

Tell us more about the drug, including whether or not it worked for you, its name, dose, and any adverse effects

How long have you had symptoms of erectile dysfunction?

0 - 3 months3 - 12 monthsLonger than 12 monthsI don't have symptoms

Enter your blood pressure reading taken within the last 6 months.

Systolic:Diastolic:

Do you suffer from depression or anxiety?

DepressionAnxietyNeither

o you use tobacco, alcohol, or drugs?

TobaccoAlcoholNone of these

How many drinks per day?

Have you ever experienced any of the following?

Inflammatory bowel disease - ulcerative colitis or Crohn's diseaseBleeding stomach or peptic ulcerPriapism (persistent, usually painful, erection that lasts for more than 4 hours)Retinitis pigmentosa (eye disease causing vision loss)Anterior ischemic optic neuropathy (loss of blood flow to the optic nerve causing sudden painless vision loss in one eye)Sickle cell diseaseBlood clotting disorder, abnormal bleeding or bruising, or coagulopathyMyeloma or leukemiaNone of these apply to me

Do you have any drug allergies?

YesNo

please describe

Are you taking any other medicines, including over-the-counter drugs, supplements, vitamins, and prescriptions?

YesNo

Anything else you would like us to know?

How would you like to pay?

Out of pocketInsuranceupload emirates insurance details (if available) Upload a Photo of your Emirates ID Upload Front Upload Back

Billing and delivery details

Google MapDelivery Location Google Map: (Please Share your Google Map Link) Delivery Location Neighborhood/Area: Street Name/No: Address Details:

Personal Details

Title: First Name: Last Name: Mobile Number: E-mail:

Insurance & Id Details

Upload Emirates ID: Insurance:

Feel free to leave any additional comments here:

Confirm Request and Agree to Terms

After you submit your request, a licensed medical provider will review your information. You will be notified by email/contact number when that provider has reviewed your request and, if appropriate, made care recommendations.

Erectile Dysfunction Survey

Erectile Dysfunction

Choose your Location

What is your date of birth?

How often are you suffering from erectile dysfunction?

Have you had a physical exam with a healthcare provider in the past 3 years that included an examination of your genitals?

Have you ever been prescribed medications, vitamins or supplements to treat it before?

How long have you had symptoms of erectile dysfunction?

Enter your blood pressure reading taken within the last 6 months.

Do you suffer from depression or anxiety?

o you use tobacco, alcohol, or drugs?

Do you have any of these conditions?

Have you ever had any of the following cardiovascular conditions?

Have you ever experienced any of the following?

Have you ever experienced any of these issues before?

Do you have any drug allergies?

Are you taking any other medicines, including over-the-counter drugs, supplements, vitamins, and prescriptions?

Anything else you would like us to know?

How would you like to pay?

Billing and delivery details

Personal Details

Insurance & Id Details

Confirm Request and Agree to Terms

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Al Thiqa Al Dowaliah Pharmacy

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