Premature Ejaculation Prescription

Start Your Consultation

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Do you agree and consent to the following?

You are completing this consultation for yourself and to the best of your knowledge.
You will disclose any medical conditions, serious illnesses or operations you have had.
You will disclose any prescription medications you are currently taking and agree to use only one weight loss treatment at a time.
You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy.
Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life-threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation.
You agree to undergo identification and age verification. This may require submitting valid documents to our approved third-party verification partner for validation.
You consent to EveryDayMeds accessing your Summary Care Record (SCR) for the purpose of ensuring the safe supply of treatment. If the SCR is unavailable or incomplete, you agree to participate in appropriate two-way communication (e.g. phone, secure message, or video consultation) to verify your medical history. If you do not respond or engage, your order will be cancelled.

Your Health

Are you male aged between 18 and 64?

Yes No

Do you drink alcohol?

Yes No

Do you suffer any pain whilst ejaculating, or do you have any difficulty or pain passing urine?

Yes No

Does premature ejaculation cause you personal distress or inter-personal difficulty with your partner?

Yes No

Do you ejaculate before you want to?

Yes No

Does it take you less than 2 minutes to ejaculate after penetration?

Yes No

Have you been suffering from premature ejaculation for more than 6 months?

Yes No

Are you allergic (hypersensitive) to Priligy or dapoxetine?

Yes No

Do you have a tendency to faint or get light-headed when you stand up from a lying position?

Yes No

Do you have low blood pressure (below 90/50)?

Yes No

Have you ever suffered from any of the following?

Depression, mania, bipolar disorder, schizophrenia
Heart disease or chest pain
History of bleeding or blood clots
Glaucoma
Kidney or prostate problems
Epilepsy
Recurrent fainting
Moderate/severe liver disease
Lactose intolerance or glucose-galactose malabsorption
Any serious medical condition requiring hospitalisation

Yes No

Medical Condition

Have you taken Priligy 30mg at least 4 times previously without any side effects and found that this strength is insufficient at reducing premature ejaculation?

Yes No

Medication

Are you currently taking any medication (prescription, over-the-counter, or recreational drugs)?

Yes No

Are you taking any of the following?

Erectile dysfunction treatments (e.g. Viagra, Cialis)
SSRIs (e.g. citalopram, fluoxetine)
Venlafaxine or TCAs
MAOIs (e.g. selegiline)
St John’s Wort
Lithium or antipsychotics
Recreational drugs (ecstasy, LSD, narcotics)
Tryptophan
Tramadol
Migraine medicines (e.g. sumatriptan)
Erythromycin, clarithromycin, linezolid
Antifungals (ketoconazole, itraconazole)
HIV medicines (ritonavir, saquinavir)
Warfarin
NSAIDs (ibuprofen, aspirin)
Blood pressure medications causing dizziness
Medicines for prostate or nausea

Yes No

Agreement

Do you understand that if you experience side effects such as mood changes or seizures, you must stop treatment and seek urgent medical care?

Yes No

Do you understand how to manage dizziness (e.g. lying down, not rising too quickly, avoiding driving)?

Yes No

Do you understand that dapoxetine is not for erectile dysfunction and should not be combined with ED treatments due to the risk of low blood pressure?

Yes No

Do you agree to the following?

Read the patient information leaflet
Inform your GP if anything changes during treatment
Use the treatment only for yourself
You’ve answered all questions truthfully
You understand incorrect info can be dangerous
You understand the prescriber’s decision is final

Yes No

Do you give us permission to access your NHS Summary Care Record or request medical history from your GP if required?

Yes No

Do you consent to us sharing relevant consultation details with your GP to ensure continuity of care?

Yes No

GP Consultation

We can notify your GP of your treatment for you. To do so, we need their contact information. Sharing this information allows your GP to maintain a comprehensive record of your medical history, which is crucial for your health. Without complete records, there could be potential risks to your well-being.

I consent to EveryDayMeds contacting my GP and share information about my prescription.

Yes No

Practice/GP Name

Practice/GP Address

Identity Verification

Please upload your identification documents.

Would you like to upload documents now?

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What you need to upload

To safely prescribe weight-loss medication, our clinicians need to verify your identity and assess your eligibility. Please upload both of the following:

Photo ID

Upload a clear photo of one valid ID document, such as:

Passport
UK driving licence
National ID card

Requirements:

The full document must be visible
Text and photo must be clear and readable
The ID must be valid (not expired)

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Tap to upload ID card

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Full-Body Photo

Take a full-body photo of yourself using your camera.

Photo guidelines:

Full body visible (head to feet)
Wear fitted clothing (no coats or baggy clothes)
Stand straight, facing the camera
No filters or edits

This photo is used only to help our clinicians assess your BMI and suitability for treatment.

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Take photo using camera

Camera required

Upload Previous Prescription

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Upload previous prescription

No file chosen

If you select this option, your order won’t be approved until all required documents are submitted. After your consultation, we’ll email you instructions on how to upload your documents.

Your Premature Ejaculation Prescription Plan

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