Order Form – Eropid

Eropid Purchase Form

Fill in this form before you purchase.

Quick note: Please fill in your information and we’ll be sending your order in no time. For your safety, we just need to ask you a few questions to check if Eropid is suitable for you. Once approved we will send you a confirmation email and confirmation phone call.

1: Are you buying Eropid for yourself?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
2: Has your doctor advised that you are not fit enough for any physical and/or sexual activity?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
3: Do you feel very breathless or experience chest pain with light/moderate physical activity e.g. walking briskly for twenty minutes or climbing two flights of stairs?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
4: Have you had a heart attack or stroke within the last six months?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
5: Do you have any other heart problems or are under a doctor’s care for any of the following? - Low blood pressure or uncontrolled high blood pressure - Unstable angina (chest pain), irregular heartbeat or palpitations (arrhythmia)*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
6: Do you have any problems with one of the valves in your heart (valvular heart disease) or a problem where your heart muscle becomes inflamed and doesn’t work as well as it should (cardiomyopathy)?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
7: Do you have any heart problems causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
8: Are you taking any nitrates for chest pain? (nicorandil or other nitric oxide donors e.g. glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate)?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
9: Are you using drugs called ‘poppers’ (amyl nitrite) for recreational purposes?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
10: Are you taking riociguat or other guanylate cyclase stimulators for lung problems?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
11: Are you taking any CYP3A4 inhibitors e.g. saquinavir (to treat HIV infection), cimetidine (for heartburn), itraconazole or ketoconazole (to treat fungal infections), erythromycin or rifampicin (antibiotics) or diltiazem (for high blood pressure)?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
12: Are you taking any alpha-blockers, such as alfuzosin, doxazosin or tamsulosin, which are medicines used to treat urinary problems due to an enlarged prostate (benign prostatic hyperplasia) or occasionally to treat high blood pressure?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
13: Do you have Peyronie’s disease or any other disease, injury or deformation of the penis?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
14: Have you ever had loss of vision because of damage to the optic nerve (e.g. non-arteric anterior ischaemic optic neuropathy [NAION]) or have an inherited eye disease (e.g. retinitis pigmentosa)?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
15: Do you have intolerance to galactose, Lapp lactase deficiency or glucose-galactose malabsorption?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
16: Do you have previously diagnosed hepatic (liver) disease (including liver cirrhosis), or severe renal (kidney) impairment?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
17: Do you have any of the following: sickle cell anaemia, multiple myeloma or leukaemia?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
18: Do you have any bleeding issues (e.g. haemophilia) or any active stomach ulcers?*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
19: Do you have any questions or concerns about this medicine that you would like to make the pharmacy team aware of?*
- Yes
- No
Please write your question here*
20: Please list any other medication (including any medication you take on 'when required' basis), or any other medical condition you suffer from below:*
- Yes
- None
Write the medication list here*
21: Please select YES to confirm that you understand that erectile dysfunction (ED) can be an early indicator of cardiovascular disease or diabetes and that, if not done so already, it is strongly advised that you consult your GP for a review*
- Yes
- No
This product may not be suitable for you to take without consulting a doctor first. You should go to see your doctor as soon as you can to discuss other suitable options.
Name*
First Last
Your email*
Your Phone*
Address*
Street Address City County / State / Region ZIP / Postal Code Country
Do you agree to the following:*
- I understand that all men with erectile dysfunction are recommended to have their blood pressure checked regularly as well as having blood tests for high cholesterol, diabetes, and hormone imbalances (such as thyroid, testosterone or prolactin)
- You will read the patient information leaflet supplied with your medication
- You will contact us and inform your GP of your medication if you experience any side effects of treatment, If you start a new medication or if your medical conditions change during treatment
- You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health Confirm
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Eropid Purchase Form

Fill in this form before you purchase.

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