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

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

Do you have any of these conditions?

Kidney problems including having had a kidney transplantLiver problemsNeurological problems like Parkinson's, multiple sclerosis or motor neuron diseaseHIVSpinal cord injury or paralysisA history of prostate or pelvic surgeriesLow testosteroneTight foreskinScarring of the genital organ. Feels like lumps or hard tissue under the skinPain during intercourse or during erectionsPeyronie's diseaseA history of radiation therapyAny condition where intercourse is not advisedNone of these apply to me

Have you ever had any of the following cardiovascular conditions?

Low blood pressureAnginaHeart diseaseHeart attackHeart surgeryHeart failureStrokeQT prolongationIrregular heartbeatHeart valve problemsHypertrophic obstructive cardiomyopathy (HCM)Peripheral vascular disease or claudicationNone of these apply to me

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

Have you ever experienced any of these issues before?

Chest pain or shortness of breath while climbing two flights of stairsChest pain or shortness of breath while walking four blocksChest pain or shortness of breath during sexUnexplained fainting or dizzinessCramping of the legs during exerciseAn abnormal heartbeatDiabetesHigh blood pressureHypothyroidism (low thyroid)Heartburn (GERD)ADHD (Attention Deficit/Hyperactivity Disorder)PTSD (Post-Traumatic Stress Disorder)Enlarged prostate (BPH)Cold soresGenital herpesFamily history of heart attack or heart diseaseHigh cholesterolNone of these apply to me

Do you have any drug allergies?

YesNo

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)

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Personal Details

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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.