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Changes to your medical status

By repeating the order, you are confirming the requested medication is working as intended, and you are not suffering from any undue side effects. If this is not the case, please do not repeat this order.

If you wish to repeat this order, please confirm that since your last order

There has to been any changes to your health
You have not started any new medication
You are not under investigation for any health conditions that have not yet been diagnosed.

If there has been any changes since your last order please do not repeat this order and fill out a new medical consultation.

Yes, there have been changes to my medical history since the last consultation

Please confirm the intended user:

Is not allergic to any of the ingredients listed
Has not been advised by their doctor to avoid sexual activity
Does not have any disease of deformity of the penis (such as Peyronie’s disease)
Does not have a penis which looks red or sore, or appears damaged or broken.

YesNo

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Please confirm the intended user:

	The High View Clinic FF 19 High View Close Leicester LE4 9LJ
	0116 319 7122