Answer seven quick questions about your general health to get the most effective clinically proven treatments for you.
DO YOU AGREE AND CONSENT TO THE FOLLOWING?
  • I am male, over 18 year old and live in Australia.
  • I shall be the sole user of any medication offered to me through this service.
  • I confirm all answers are provided by me, and will be truthful.
  • I agree to the terms and conditions.
Takes 4 min
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1
You must be over 18 years old and male to use this service. Please enter your date of birth *
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2
Do you have, or have you ever had, any heart or neurological or psychiatric conditions or any of the conditions listed below?
  • Heart attack, stroke, or mini-stroke within the last 6 months
  • Chest pain symptoms or any heart rhythm issues
  • Heart valve problems
  • Disease of the heart muscles
  • Get breathless or have chest pain with light exertion, such as walking briskly for 20 minutes or climbing two flights of stairs
  • History of mania or severe depression
  • Taking SSRI or antidepressant
  • Concomitant treatment with monoamine oxidase inhibitors (MAOIs) or thioridazine *
3
Please tell us more about what heart or neurological or psychiatric conditions you do have?

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4
Do any of the listed medical conditions apply to you?
  • Significant liver problems (such as cirrhosis of the liver) or kidney problems
  • Currently prescribed GTN, Isosorbide mononitrate, Isosorbide dinitrate , Nicorandil (nitrates) or Rectogesic ointment
  • Abnormal blood pressure (lower than 90/50 mmHg or higher than 160/90 mmHg), orthostatic hypotension or syncope.
  • Condition affecting your penis (such as Peyronies Disease, previous injuries or an inability to retract your foreskin)
  • History of loss of vision in one eye because of damage to the optic nerve (non-arteritic ischaemic optic neuropathy) or a hereditary retinal problem such as retinitis pigmentosa
  • Galactose intolerance, Glucose-galactose malabsorption or Lapp lactase deficiency (this is different to Lactose intolerance)
  • Any bleeding conditions (e.g. haemophilia) or any stomach/duodenal ulcer in the last 3 months
  • Hypersensitivity to any medications or excipients.
  • History of priapism (prolonged erection for more than 4 hours continuously)
  • Upcoming cataract surgery. *
5
Are you taking any of the following drugs?
  • Alpha-blocker medication such as Alfuzosin, Doxazosin, Tamsulosin, Prazosin, Terazosin or over-the-counter Flomax
  • Riociguat or other guanylate cyclase stimulators (for lung problems)
  • Saquinavir, Ritonavir or Indinavir (for HIV)
  • Cimetidine (for heartburn)
  • Ketoconazole or Itraconazole (for fungal infections)
  • Erythromycin or Clarithromycin (antibiotics)
  • Diltiazem (for high blood pressure)
  • Recreational drugs known as “Poppers” or “Cocaine” *
6
Are you taking any medications (including over the counter or herbal medicines)? Do you have any other medical condition or previous operations not already mentioned? *
7
Please list all your medications you take and any other medical conditions or previous operations.

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8
Have you taken Sildenafil (Viagra)/equivalent, Silodosin (Urodec), or Dapoxetine (Priligy) before? *
9
What dose have you taken before? For example: 25mg, 50mg or 100mg

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10
Would you like to see treatment options now without speaking with a doctor? *
11
Discretion is at the heart of what we do but for legal reasons the name on your prescription must be your full legal name. Please provide your legal name as per your official government ID. *

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12
Based on your medical history and individual needs, our doctors have provided personalised treatment. Please complete your mobile phone number to view recommended treatment. *
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Unfortunately based on your answer you would not be suitable for treatment. If you would like to speak with the Burst doctor to discuss other treatment options, please book an appointment here.
If you made a mistake, you can go back and correct your answer.
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Please follow this link to book a$85 consultation with our doctor:
click here to book
If you made a mistake, you can go back and correct your answer.
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Thank you for filling out the form.

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