Erectile Dysfunction Survey

Erectile Dysfunction

There are only a few steps to get started.

    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?

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

    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?

    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?

    How many drinks per day?

    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?

    please describe

    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?

    upload emirates insurance details (if available)

    Billing and delivery details

    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