Simple Online Doctor

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Patient Notice! You will be asked to complete an assessment before purchasing this medication. This assessment forms the basis of your premature ejaculation consultation today. We need you to be honest with your answers including any current medication you are on. This allows our doctors to safely prescribe medication and offer accurate advice. We expect you to read the medicinal information provided before using your treatment.

1Your premature ejaculation

What was your sex registered at birth? (i.e. your biological sex) *

Do you often ejaculate within 2 minutes of sexual penetration? *

NoYes

Please provide more information below. *

Do you find it difficult to control when you are going to ejaculate? *

NoYes

Have you been experiencing problems with premature ejaculation for at least 6 months? *

NoYes

Is premature ejaculation causing you distress or difficulty in your relationship with your partner(s)? *

NoYes

Are you aged between 18-64? *

NoYes

Unfortunately, you are not a suitable age for these treatments. Please discuss treatment options with your regular GP.

ID and age verification are required prior to receiving treatment.

Do any of the following conditions apply to you? Select all that apply; *

Erectile dysfunction (difficulty getting or maintaining an erection)An overactive thyroid (hyperthyroidism)Prostate disorders or prostate surgeryChronic pain in your pelvisNone of the above

Do you have or have you ever had any of the following?

Epilepsy or seizure
Fainting
Dizziness when you stand up after lying down
Bleeding or clotting disorder
Any heart conditions
Problems with your liver or kidneys
Any mental health conditions e.g. depression, anxiety, bipolar disorder, mania

NoYes

Please provide more information below. *

2Your health

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs? *

NoYes

Please list any prescription, over the counter or alternative medicines you are taking, including the dose. *

Do you have any known allergies to Priligy or it's contents? The active ingredient is Dapoxetine. If in doubt, please read the drug profile here (https://www.nps.org.au/assets/medicines/b9e2de63-13ad-49cc-a55d-a53300ff80fb.pdf) *

NoYes

Please list your known allergies. *

Is there any other information you feel would be useful for our clinicians to know about? *

NoYes

Please provide more information *

I understand that premature ejaculation can be caused by drinking too much alcohol, or using recreational drugs such as cocaine. *

Confirm

3Consent

I confirm I am over 18 years old.

The medicine ordered is for my sole use only.

I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.

I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.

I agree to the Simple Online Doctor terms and conditions. *

Confirm

We strongly advise that you inform your GP of any treatment you receive.
Would you like us to inform them on your behalf? If you are unsure, you can search your GP clinic information by clicking here.

NoYes

Please enter the email address of your GP clinic *

As per Australian telehealth guidelines, all first time patients, those requesting a new treatment or those looking to renew a prescription must have a brief video or phone call with one of our doctors. Do you have reliable access to the internet on a device which you can use to have a video conversation with our doctors? *

NoYes

You require reliable access to the internet on a device which you can use to have a video consultation with the doctor in order to be suitable for telehealth. Please refer to your regular GP in person.

During your consultation, our doctor will assess whether you are suitable for treatment. If you are, a prescription will be provided to and filled by our pharmacy partner and delivered to your chosen address. Any and all resupplies will be stored on your account and will be available for request from our service when required. For resupplies you will only need to pay for the medication and shipping, you will not be charged a consultation fee. Please confirm you understand this information. *

Confirm

If we are unable to assist via a telehealth consultation, you may be asked to seek alternative medical care such as that of a doctor in person. If this occurs you will receive a refund on your request.

Simple Online Doctor is a private clinic; the consultation and medication may be eligible for rebates through your private health cover, but are not covered by Medicare or the PBS. We conduct regular price reviews to ensure we are providing among the best value online.

Did you have difficulty understanding the English that is written in this assessment, affecting your ability to provide accurate answers or do you require language interpretation during a verbal consultation? *

NoYes

As you have difficulty understanding the assessment and or require interpretation services, you will be required to have an interpreter with you during your consultation with the doctor. You can access these services at Translating and Interpreting Services. Please confirm that you agree to organise an interpreter for your consultation.

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Assessment

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2Your health

3Consent

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