This online form for Viagra Connect will save you time on your visit to Hickey’s Pharmacy. If you request the pharmacist to call you, most of the consultation can occur by phone before you visit the store. Otherwise, the pharmacist will have your form ready and they will have a private consultation with you in the store. This takes a few minutes to complete.

This product is only available to men aged 18 or over. (If you are under 18 please contact your GP to discuss your options)

Viagra Connect is only intended for use in men who are experiencing erectile dysfunction (ED) i.e. difficulty in getting and/or maintaining an erection satisfactory for sexual performance.

General Health

  • Low blood pressure or uncontrolled high blood pressure
  • Unstable angina (chest pain), irregular heart beat or palpitations (arrhythmia)
  • A problem with one of the valves in your heart (valvular heart disease)
  • A problem where the heart muscle becomes inflamed and does not work as well as it should (cardiomyopathy)
  • Heart problems causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure

Other Information

Some men are on medication or have certain health conditions that could make Viagra Connect unsafe to take. The following questions help the pharmacist establish if Viagra Connect is suitable for you.

Please enter a full list of all regular medication on this form or bring a list with you when you come to the pharmacy.

Select a store

What Happens Next?

Once you click submit, your chosen pharmacy will receive your details. The pharmacist will review the information you have provided. If you request a phone consultation by entering your phone number below the pharmacist will call you to carry out most of the consultation over the phone. Your medication will be ready for collection within 1 hour (during store opening hours). You will still need to come to the pharmacy yourself to collect the medication.

Contact Phone Number