Consultation Questionnaire | Tees Online Doctor

Part 4 of 4

Further Advice & Declaration

I understand ED may have physical or psychological causes including cardiovascular disease, diabetes, anxiety or alcohol use.

Yes

Serious Side Effects Warning:

I understand I must seek immediate medical attention for chest pain, erection lasting more than 4 hours, sudden vision loss, allergic reactions, severe skin reactions, or seizures.

Patient Declaration:

I confirm I am aged between 18 and 75 and this consultation is for myself.

I confirm all information provided is accurate and complete.

I understand this service is not for emergencies and treatment is not guaranteed.

I consent to a UK-registered clinician reviewing my information.

GP Notification Consent:

I consent to my GP being informed.

I do not consent to my GP being informed at this time.

I have read and agree to the Privacy Policy and Terms and Conditions.

CQC Regulated

GPhC REGISTERED

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