Medical Form - His Clinic

Please provide details of your medication, herbs or supplements:

Medication Details

Do you have, or have you ever had, Heart Disease?

Yes

No

We’re sorry, you don’t qualify.

You’ve mentioned that you have experienced Heart Disease. This means that you don’t qualify to view or purchase our prescription products. Made a mistake? If you think there’s been a mistake, please contact us.

Contact Us

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Do you frequently experience lightheadedness?

Yes

No

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We’re sorry, you don’t qualify.

Our prescription products are designed for male’s only, and you’ve mentioned that you’re female. If you have a male partner and they’re struggling with ED, why not open up the conversation and invite them to complete our online medical form. Made a mistake? Click to go back and double check your answers.

Contact Us

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We’re sorry, you don’t qualify.

You’ve mentioned that you’re under 18 years old. This means that you don’t qualify to view or purchase our prescription products. Made a mistake? Click to go back and double check your answers.

Contact Us

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We’re sorry, you don’t qualify.

You’ve mentioned that you’re over 75 years old. This means that you don’t qualify to view or purchase our prescription products.

There may be alternative solutions for you. Check out our treatments page to view other solutions.

Contact Us

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We’re sorry, you don’t qualify.

You’ve indicated that you have health conditions that make you ineligible to purchase our prescription products. There may be alternative solutions for you. Check out our treatments page to view other solutions. If you feel that we’ve made a mistake, please contact us so that we can re-evaluate your prescription needs. Made a mistake? Click to go back and double check your answers.

Contact Us

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We’re sorry, you don’t qualify.

Oh no! You haven’t had your blood pressure checked within the last 12 months. You can have your blood pressure checked for free by your local doctor. After that, we’ll be able to help. Made a mistake? Click to go back and double check your answers.

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Welcome to His Clinic Telehealth Platform.

Connecting you with qualified medical professionals.

Telehealth eases access to medical care, however it is always preferable to see a doctor face to face. We know that many men would rather ignore certain issues than see a doctor face to face- that’s where His Clinic™️ can help.

However, please read the telehealth guidelines before deciding if telehealth is right for you. If and once you’re ready, please feel free to enter the virtual practice.

You will be able to communicate with a registered physican directly via the “Speak to the Doctor” portal on you account.

By continuing this text-based consultation you are agreeing to the use of telehealth services.

Get Started

What is your sex?

Male

Female

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What is your date of birth?

Date of Birth (dd/mm/yyyy)

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What is your height and weight?

Height (Centimeters)

I do not know

Weight (Kilograms)

I do not know

Continue

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What is your main diet?

Mixed Diet

Pescatarian

Vegan

Vegetarian

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If prescribed, how often do you anticipate using this treatment for sexual activity?

1 - 4 uses per month

4 - 12 uses per month

12 -28 uses per month

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Do you ever have a problem getting or maintaining an erection?

Yes, every time

Yes, more than half the time

Yes, on occasion

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If you haven’t previously been approved by a doctor to use these medications, you will need to have a short phone call with one of our male doctors.

Have you ever been prescribed or approved by a doctor to take Sildenafil or Cialis?

Yes

No

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Have you previously used any of the following products?

Sildenafil

Cialis

Daily Cialis

None

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Do you have any past or ongoing medical conditions?

Yes

No

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Please provide as much detail as possible about your ongoing medical conditions:

Ongoing Medical Conditions

Have you had a history of hospital admission or surgeries?

Yes

No

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Please provide details about your history of hospital admission or surgery:

Year of hospital admission or surgery

Details about your hospital admission or surgery

ADD MORE

Do you have any allergies?

Yes

No

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Please provide as much detail as possible about your allergies:

Your allergies

such as Amyl nitrate, GTN patch, Mononitrates, nitroglycerins

Are you currently taking any Nitrate medications?

Yes

No

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Are you taking any other medications, herbs or supplements?

Yes

No

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You need to have your blood Pressure (BP) checked within the last 12 months to receive treatment.

Yes - It’s been checked

No - I haven’t had it checked

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When your blood pressure was taken were you diagnosed with:

Hypertension (high blood pressure)

Hypotension (low blood pressure)

No, it was normal

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Do you frequently experience lightheadedness?

Yes

No

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Do you have any of the following cardiovascular symptoms?

Abnormal heart beats (rapid, irregular, slow, murmurs)

Chest pain (angina) or shortness of breath

Episodes of unexplained fainting or dizziness

Cramping pain in the calves or thighs with exercise

None apply

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Have you had a heart attack in the last 6 months?

Yes

No

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Have you ever had a stroke or TIA?

Yes

No

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Do you have now, or have you ever had, any of the following conditions?

Multiple Sclerosis or a similar disease, spinal injuries or paralysis or neurological diseases

Surgery or radiation to the prostate or pelvis

Stomach, intestinal or bowel ulcers

Liver Disease

Kidney transplant (or conditions affecting the kidney)

None apply

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Do you have any of the following conditions?

A marked curve or bend in the penis that inteferes with sex, or Peyronie’s disease

Fibrous tissue in the penis (lumps and bumps under the skin that feels hard)

Pain with erections or ejaculation

A foreskin that is too tight

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You're almost there!

Thanks for filling in your details! Please create your account so that our doctors can get back to you after they’ve reviewed your details.

Full Legal Name for Prescription

Email

Create Password

* password must contain at least 6 characters, an uppercase character and a number.

Create Account

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Your medical assessment needs further review

Based on your answers you have unspecified health conditions or a history of prior surgeries. Please input the details about these circumstances so that we can ensure our products are safe for you to use. You’ll be able to purchase our products after your medical information has been reviewed.

Medical Details

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Please provide details of your medication, herbs or supplements:

Do you have, or have you ever had, Heart Disease?

We’re sorry, you don’t qualify.

Do you frequently experience lightheadedness?

We’re sorry, you don’t qualify.

We’re sorry, you don’t qualify.

We’re sorry, you don’t qualify.

We’re sorry, you don’t qualify.

We’re sorry, you don’t qualify.

Welcome to His Clinic Telehealth Platform.

Connecting you with qualified medical professionals.

What is your sex?

What is your date of birth?

What is your height and weight?

What is your main diet?

If prescribed, how often do you anticipate using this treatment for sexual activity?

Do you ever have a problem getting or maintaining an erection?

If you haven’t previously been approved by a doctor to use these medications, you will need to have a short phone call with one of our male doctors.

Have you ever been prescribed or approved by a doctor to take Sildenafil or Cialis?

Have you previously used any of the following products?

Was Sildenafil effective?

Was Cialis effective?

Was Daily Cialis effective?

Do you have any past or ongoing medical conditions?

Please provide as much detail as possible about your ongoing medical conditions:

Have you had a history of hospital admission or surgeries?

Please provide details about your history of hospital admission or surgery:

Do you have any allergies?

Please provide as much detail as possible about your allergies:

such as Amyl nitrate, GTN patch, Mononitrates, nitroglycerins

Are you currently taking any Nitrate medications?

Are you taking any other medications, herbs or supplements?

You need to have your blood Pressure (BP) checked within the last 12 months to receive treatment.

When your blood pressure was taken were you diagnosed with:

Do you frequently experience lightheadedness?

Do you have any of the following cardiovascular symptoms?

Have you had a heart attack in the last 6 months?

Have you ever had a stroke or TIA?

Do you have now, or have you ever had, any of the following conditions?

Do you have any of the following conditions?

You're almost there!

Your medical assessment needs further review

Please provide details of your medication, herbs or supplements:

Do you have, or have you ever had, Heart Disease?

We’re sorry, you don’t qualify.

Do you frequently experience lightheadedness?

We’re sorry, you don’t qualify.

We’re sorry, you don’t qualify.

We’re sorry, you don’t qualify.

We’re sorry, you don’t qualify.

We’re sorry, you don’t qualify.

Welcome to His Clinic Telehealth Platform.

Connecting you with qualified medical professionals.

What is your sex?

What is your date of birth?

What is your height and weight?

What is your main diet?

If prescribed, how often do you anticipate using this treatment for sexual activity?

Do you ever have a problem getting or maintaining an erection?

If you haven’t previously been approved by a doctor to use these medications, you will need to have a short phone call with one of our male doctors. Have you ever been prescribed or approved by a doctor to take Sildenafil or Cialis?

Have you previously used any of the following products?

Was Sildenafil effective?

Was Cialis effective?

Was Daily Cialis effective?

Do you have any past or ongoing medical conditions?

Please provide as much detail as possible about your ongoing medical conditions:

Have you had a history of hospital admission or surgeries?

Please provide details about your history of hospital admission or surgery:

Do you have any allergies?

Please provide as much detail as possible about your allergies:

such as Amyl nitrate, GTN patch, Mononitrates, nitroglycerins Are you currently taking any Nitrate medications?

Are you taking any other medications, herbs or supplements?

You need to have your blood Pressure (BP) checked within the last 12 months to receive treatment.

When your blood pressure was taken were you diagnosed with:

Do you frequently experience lightheadedness?

Do you have any of the following cardiovascular symptoms?

Have you had a heart attack in the last 6 months?

Have you ever had a stroke or TIA?

Do you have now, or have you ever had, any of the following conditions?

Do you have any of the following conditions?

You're almost there!

Your medical assessment needs further review

If you haven’t previously been approved by a doctor to use these medications, you will need to have a short phone call with one of our male doctors.

Have you ever been prescribed or approved by a doctor to take Sildenafil or Cialis?

such as Amyl nitrate, GTN patch, Mononitrates, nitroglycerins

Are you currently taking any Nitrate medications?