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Premature Ejaculation Prescription

Medical Assessment

Answer a few quick and easy questions from our pharmacists to see what treatments you’re eligible for.

Your Health

Are you male and aged between 18-64?

Yes No

Upon commencement of sexual activity, do you:

Ejaculate within 2 minutes
Before you wish to or shortly after penetration
Ejaculate with minimal sexual stimulation

Yes No

Does this condition cause you or your partner distress or interpersonal difficulty?

Yes No

Have you been suffering from premature ejaculation for at least the past 6 months?

Yes No

Do you experience any pain when ejaculating, or pain when passing urine?

Yes No

Are you allergic or hypersensitive to dapoxetine or any of the other ingredients in Priligy?

Yes No

Do you have low blood pressure (below 90/50) or have a tendency to feel light-headed when standing up from a lying down position?

Yes No

Have you used Priligy 30mg previously without experiencing side effects and found this strength insufficient at treating premature ejaculation?

Yes No

Medical Conditions

Do you have any of the following conditions:

Renal (kidney) impairment
Hepatic (liver) impairment
Heart failure or any other heart conditions (e.g. ischemic heart disease, valvular disease, angina or irregular heart beat)
History of bleeding disorders
History of syncope (fainting)
History of mania or severe depression
Raised intraocular pressure or at risk of angle closure glaucoma
Galactose intolerance, the Lapp lactase deficiency, or glucose-galactose malabsorption
Epilepsy or history of seizures
Prostate problems

Yes No

Medication

Do you take any other medication?

Yes No

Do you take any of the following medications:

Treatment for erectile dysfunction (sildenafil, vardenafil, tadalafil)
Monoamine oxidase inhibitors to treat depression (MAOIs), either currently using or used in the last 14 days (moclobemide, phenelzine, tranylcypromine)
Selective serotonin reuptake inhibitors (SSRI´s) (fluoxetine, paroxetine, etc)
Selective norepinephrine reuptake inhibitors (SNRI´s) such as (venlafaxine, duloxetine, etc)
Tricyclic antidepressants (amitriptyline, nortriptyline)
Tryptophan
5HT1 antagonists (sumatriptan, zolmitriptan, frovatriptan)
Tramadol
St. John´s Wort
Anti-fungal medication (ketoconazole, itraconazole, fluconazole)
HIV medications (ritonavir, saquinavir, nelfinavir, atazanavir)
Antibiotics (Erythromycin, clarithromycin or telithromycin, linezolid)
Alpha blockers (alfuzosin, doxazosin, tamsulosin)
Medication used to treat enlarged prostate such as finasteride
Medicines used to treat high blood pressure and chest pain (angina) that can cause dizziness e.g. nitrates, verapamil, diltiazem, doxazosin, atenolol, metoprolol and bisoprolol
Products known to affect platelet function such as phenothiazines (prochlorperazine, chlorpromazine), or anti-coagulants and anti-platelets such as aspirin, clopidogrel and warfarin
Non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen or aspirin
Any CNS active medicinal products such as antiepileptics, antidepressants such as nefazodone, antipsychotics such as thioridazine, anxiolytics, lithium, or sedative hypnotics
Any recreational drugs such as ecstasy, LSD, narcotics or benzodiazepines
Aprepitant

Yes No

Agreement

Do you understand that if any light- headedness is experienced, you should immediately lie down so your head is lower than the rest of the body, or sit down with your head between your knees until the symptoms pass? Do not rise quickly after prolonged lying or sitting. Driving or operating machinery must also be avoided if you experience dizziness, drowsiness or blurred vision.

Yes No

Do you understand that Priligy (dapoxetine) does not treat erectile dysfunction? Taking erectile dysfunction medications alongside Priligy can increase the risk of low blood pressure.

Yes No

Do you understand that you should:

Avoid grapefruit juice within 24 hours prior to taking Priligy as it can affect the amount of medication in the body
Stop taking Priligy and see a doctor straight away if you experience side effects such as fits or changes in mood

Yes No

Do you agree to the following:

You will read the patient information leaflet before using this medication
You are aged 18 years or over
You have answered all questions truthfully and accurately
If you have an NHS Summary Care digital record, our specialists can check it to ensure this medication is safe for you
You understand that we take your answers in good faith and any false or incorrect information given can be hazardous to your health
This treatment is solely for your own use
You will inform your GP that you have been prescribed this medication if this is appropriate
You will contact us and inform your GP if you experience any side effects with your treatment, you start any new medication/your medical conditions change during treatment
You are capable of making your own decision about your healthcare and have the capacity to do so

Yes No

GP Details

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 YourMedicals contacting my GP and share information about my prescription.

Yes No

Practice/GP Name

Practice/GP Address

Verify your BMI

To comply with regulations and ensure the safe provision of weight loss treatment, we need to verify your BMI. You may complete this step later, but we cannot proceed with your prescription until it is provided.

Upload Now Upload Later

Upload Your ID

Please upload a government-issued photo ID that meets the following criteria:

Clearly shows your face, name, and date of birth.
Ensure the image is free from reflections and blurriness.
All four sides of the ID must be visible.

Why We Request a Photo ID

We prioritise your safety and ensure compliance with medical regulations. Our prescribing team requires a government-issued photo ID to:

Verify your identity.
Ensure that all information you have provided matches the details on your ID.

Your information is handled with the utmost confidentiality and security

Upload ID

You have chosen to upload your documents at a later time. A confirmation email will be sent to you shortly with instructions for uploading.

Please note, your order will be placed on hold until the required documents are uploaded. Once the documents are provided, we will proceed with processing your order.

Complete our 2 minute questionnaire

Confidential

Our prescribers will carefully review your information with full confidentiality.
Your medication will be delivered in plain, unmarked packaging
All data is securely encrypted using 128-bit SSL encryption.

Need help?

If you require assistance with this medical assessment, please reach out to our support team:: 0116 507 0486

Your Premature Ejaculation Treatments

Priligy (Dapoxetine) Tablets

Strength Quantity

£31.99

Need Some Extras?

Valupak Multivitamin

£1.99

Valupak Vitamin D3 1000IU (25mcg) - 60 Capsules

£1.99

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