Online Consultation

Please answer all questions honestly and completely so our health professional can ensure suitability and prevent any delays in supplying your medication

Are you purchasing this medication for yourself?
Are you over 18 and under 65 years old?
Have you previously been diagnosed with premature ejaculation?
Do you have difficulty or poor control over ejaculation?
Over the last six months, in the majority of intercourse attempts, have you prematurely ejaculated?
Are you experiencing mental or emotional distress because of premature ejaculation?
Do you normally ejaculate within 2 minutes of vaginal penetration?
Do you have any of the following conditions?
  • Renal impairment
  • Hepatic impairment
  • Heart failure
  • Conduction abnormalities such as AV block or sick sinus syndrome
  • Ischemic heart disease
  • Valvular disease
  • History of syncope or postural hypotension
  • History of bipolar disorder, mania or severe depression
  • Uncontrolled epilepsy
  • bleeding disorders
  • Raised intraocular pressure or are you at risk of angle closure glaucoma
Do you take any of the below medication?
  • Monoamine oxidase inhibitors such as phenelzine
  • Thioridazine
  • Antidepressants such as SSRIs (citalopram, escitalopram, fluoxetine, paroxatine, sertraline) SNRI’s (duloxetine, venlaflaxine), linezolid, lithium,amitriptyline,clomipramine, imipramine, Nortriptyline, St Johns Wort.
  • clarithromycin
  • nicotinic acid
  • Triglyceride-reducing drugs (omega-3-adid ethyl esters, volanesorsen)
  • Antifungals (Itraconazole, Ketoconazole, Isavucanazole, posacanzole or Voriconazole)
  • HIV Protease Inhibitors or pharmacokinetic enhancers (Atazanavir, Cobicistat, Darunavir, Fosamprenavir, lopinavir, Ritonavir, Saquinavir, Tipranavir)
  • protease kinase inhibitors (idelalisib)
  • Alpha Blockers (Doxazosin, Alfuzosin, Prazosin, Tamsulosin, Indoramin or Terazosin)
  • Nitrates (nicorandil, Isosorbide mononitrate, isosorbide dinitrate, glyceryl trinitrate)
  • Any other antiepileptics, antidepressants, antipsychotics, anxiolytics or sedative hypnotics (such as diazepam)
  • Medication for bleeding disorders including Warfarin, Acenocoumarol, Alteplase, Apixaban, Argatroban, Bivalirudin, Caplacizumab, Dabigatran, Danaparoid, Edoxaban, Enoxaparin, Fondaparinux, Heparin, Phenindione, Rivaroxaban, streptokinase, tenecteplase, Tinzaparin, Urokinase
  • Any treatments for erectile dysfunction such as sildenafil or tadalafil.
Do you take any other medication?
Do you use any recreational drugs?
Do you have any allergies?
Do you have a hereditary intolerance to galacotose, lapp lactase deficiency or glucose-galactose malabsorption.
I will read the patient information leaflet before using any provided treatments.
Can we pass on details of your treatment to your GP?
I agree that
  • All questions have been answered to the best of my knowledge.
  • I am happy for pharmacists to review my consultation and prescribe the item requested if it is clinically suitable for myself.
  • I understand my treatment request may be rejected due to clinical or other reasons.
  • The treatment is solely for my own use and not for the use of others.
  • I consent for Menschem to undertake an ID check to confirm my age and identity. (This will be done using a credit check agency, no record will be put on your credit rating).