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—Please choose an option—Abu DhabiAl AinDubaiSharjahAjman
Tell us Which erectile dysfunction medicine have you taken before?
Every timeSometimesHardly ever
Less than 3 months3 to 12 monthsmore than 1 year
YesNoDon't think about sex or want to have sex
EverytimeSometimesHardly everI can't ejaculate at allNever ejaculate sooner than you or your partner want to
Not at allA littleSomewhatMuchVery much
YesNoI don't have problems with ejaculation
Smoke cigarettes or use tobacco productsDrink more than 2 alcoholic beverages per dayNone apply
Any condition where sex is not recommendedKidney problems including having had a kidney transplantLiver problemsNeurological problemsHIVParalysis or spinal cord damagePrevious prostate or pelvic surgery or radiation therapyLow testosteroneNone apply
Write NA, if there is no physical issue.
Write NA, if you don’t have any problem.
DiabetesHigh blood pressureHigh cholesterolHypothyroidism (low thyroid)Heartburn or GERDDepressionAnxietyADHD (Attention Deficit/Hyperactivity Disorder)PTSD (Post-Traumatic Stress Disorder)BPH (enlarged prostate)Cold soresGenital herpesNone apply
Please list your drug allergies and what happens when you use that drug.
Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.
In order for us to provide you with the best care, please let us know what medications you take and what conditions you have.
NoneHistory of kidney problemsHistory of liver problemsA diagnosed immune disorderOther
Tell us about any concerns or questions you have for the medical team.
Out of pocketInsuranceupload emirates insurance details (if available)
Google MapDelivery Location Google Map: (Please Share your Google Map Link)
First Name: Last Name:
Mobile Number: E-mail:
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.