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Name: UsMen
Address: 1 Acre House Avenue, Lindley, Huddersfield, HD3 3BB, Huddersfield, HD3 3BB
Telephone: 01484 917696

For assistance call 01484 917696 or email prescribers@usmen.co.uk

answer questions BELOW

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Are you male and over 18?*

Yes

We are unable to safely prescribe this treatment for you at this time. For further information, please contact the pharmacy on 01484 917696 or email our prescriber on prescribers@usmen.co.uk

Do you smoke?*

Yes

Are you using this medication to treat erectile dysfunction (symptoms of ED include difficulty getting and/or maintaining an erection)?*

Yes

We are unable to safely prescribe this treatment for you at this time. For further information, please contact the pharmacy on 01484 917696 or email our prescriber on prescribers@usmen.co.uk

Have you previously used or currently using medication to treat erectile dysfunction ?*

Yes

Please tell us which medication you have been taking if you recall

Has your doctor advised you to avoid sexual activity?*

Yes

Please briefly explain why your Doctor has advised you not to have intercourse

Do you suffer from any allergies or intolerances?*

Yes

Please briefly explain your intolerances or allergies

Do you suffer from any of the medical conditions below?*

Heart attack or stroke within the last 6 months?
Difficulty breathing or chest pain with light/moderate physical activity, such as walking at a fast pace.
Low blood pressure (below 90/60) or uncontrolled high blood pressure (over 140/90).
Unstable angina (chest pain) or irregular heart beat (arrhythmia)
Heart valve problems (e.g. valvular heart disease) or an inflamed heart muscle (cardiomyopathy).
Heart blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure.

Yes

Please provide further details.

Do you have any of the below*

Loss of vision (due to optic nerve damage such as NAION) or inherited eye conditions (such as retinitis pigmentosa)?
Galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption?
Liver or kidney disease?
Sickle cell anaemia, multiple myeloma or leukaemia?
Any bleeding issues (e.g. haemophilia) or active stomach ulcers?
Physical deformity of the penis such as Peyronie’s disease.

Yes

Please provide further details.

Are you taking any of the following medication?

Nitrates (nitric oxide donors e.g. nicorandil, glyceryl trinitrate, isosorbide mononitrate/dinitrate) for chest pain?

Recreational drugs such as ‘poppers’ (e.g. amyl nitrite)?

Guanylate cyclase stimulators for lung problems (e.g. riociguat), protease/ CYP3A4 inhibitors (e.g. ratanovir, saquinavir) to treat HIV infection.

Heartburn treatment (e.g. cimetidine), antifungals (e.g. itraconazole or ketoconazole), antibiotics (e.g. erythromycin or rifampicin),a high blood pressure (e.g. diltiazem).

Alpha-blockers (e.g. alfuzosin, doxazosin or tamsulosin) for enlarged prostate or occasionally to treat high blood pressure.

Antiepilepics (e.g. carbamazepine, phenobarbital, phenytoin, primidone, fosphenytoin).

Antidepressants (e.g. citalopram).

Cancer drugs (e.g. nilotinib).

Are you taking any of the following medication?

None of the above

In order for us to prescribe this medication safely to you, please provide details of dosage and frequency along with any other information our prescriber needs to know?

Please read the below and confirm that you understand and agree*

I have answered all of the above questions truthfully and confirm that the medication is for myself.

I should regularly have my blood pressure, glucose, cholesterol and hormone levels checked with my GP.

I consent for UsMen to carry out an ID check to verify my age and identity (this will not affect your credit score).

If ordering the higher dose, I confirm I have tried the lower dose and will take the medication as prescribed.

I confirm that I do not take nitrates or recreational drugs such as poppers/cocaine with ED medication as this can be very dangerous

We collect information about your health to make a medical diagnosis and prescribe medicines safely. Under the GDPR this type of data is classed as sensitive and therefore we take further precautions when collecting and processing it. By consenting to this notice, you are giving us permission to process your health data for the purposes of prescribing medicine.

I agree for the prescribers at UsMen to treat my medical condition and that the medication request maybe rejected due to clinical or other reasons.

If any unusual side effects are experienced, I will inform a medical professional.

I agree to read the patient information leaflet before commencing treatment and will contact a healthcare professional if I have any questions.

I am responsible for informing my GP of the medication supplied. If you would like us to inform your GP on your medication with us , please email us on hello@usmen.co.uk with your full name and GP contact details.

I consent to being contacted in relation to my order, any product and service updates, offers and news related to USMEN

I have read and accept the terms and conditions and privacy policy.

Yes

Sorry! Unfortunately based on the answers you have provided we can not treat you at this time, if you wish to discuss please head to our Contact Us page to discuss further

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