What is your date of birth?

Have you taken erectile dysfunction medicine before?

YesNo

Do you ever have difficulties getting or maintaining an erection that is satisfying enough for sex BEFORE ejaculation?

YesNo

How often do you have a problem with this?

Every timeSometimesHardly ever

Did your problem with your erection start suddenly?

YesNo

How long have you experienced a problem getting or maintaining an erection that is enough?

Less than 3 months3 to 12 monthsmore than 1 year

What is your blood pressure reading taken within the last 6 months?

Are you worried about having sex?

YesNoDon't think about sex or want to have sex

How often do you ejaculate sooner than you or your partner want to?

EverytimeSometimesHardly everI can't ejaculate at allNever ejaculate sooner than you or your partner want to

Do you Ejaculate with very little stimulation?

Not at allA littleSomewhatMuchVery much

Are you stressed, annoyed, or frustrated by ejaculation problems?

YesNoI don't have problems with ejaculation

How often have you had symptoms of depression or anxiety?

Not at allA littleSomewhatMuchVery much

Do you….?

Smoke cigarettes or use tobacco productsDrink more than 2 alcoholic beverages per dayNone apply

Do you have any of these conditions?

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

Tell us if you have any physical issues with your penis that make intercourse difficult

Write NA, if there is no physical issue.

Tell Us if you ever had any heart problems , low blood pressure, stroke, or circulation problems where taking ED medicines can be life-threatening

Write NA, if you don’t have any problem.

Have you ever been diagnosed with any of the following? Select all that apply to you

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

Have you ever taken or been prescribed nitrates or nitroglycerin or alpha blockers (doxazosin, prazosin or terazosin)?

YesNo

Are you allergic to any medicine?

YesNo

Do you take other medication(s) or have any other medical conditions?

Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.

YesNo

Do you have any of these conditions?

NoneHistory of kidney problemsHistory of liver problemsA diagnosed immune disorderOther

Anything else you would like us to know?

YesNo

How would you like to pay?

Out of pocketInsuranceupload emirates insurance details (if available)

Upload a Photo of your Emirates ID
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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: Mr.Ms.
First Name: Last Name:
Mobile Number: E-mail:

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.