EDCheck Patient Registration Form

  • Erectile Dysfunction Consultation Form

    Please fill out this form to register for our telehealth service. We provide consultations and prescriptions for medications such as Viagra and Cialis.
  • Do you have a Medicare Card?*

  • If you do not have a Medicare Card we will need your Individual Health Identifier (IHI). This is available to everyone, including those people without a Medicare card. Without an IHI we are unable to send your prescriptions electronically to your phone or email.
    For information on how to apply for an IHI go to Services Australia

  • Do you have a regular GP?*
  • Would you like us to let your GP know you have consulted with us and advise them of any medications we have prescribed?*
  • Date of Birth*
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  • Do you currently have any of the following medical conditions? (Select all that apply. Leave blank if none apply.)
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  • Do you currently take any of the following medications? (Select all that apply. Leave blank if none apply.)
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  • Do you have any allergies to medications?*
  • Have you used any of the following ED Medications before?

  • ED Assessment

  • How long have you experienced issues with your erections?*
  • How often do you experience difficulty achieving or maintaining an erection?*
  • Do you wake up with morning erections?*
  • Do you believe your erectile issues is related to any of the following?*

  • Treatment Preferences

  • How often do you anticipate needing ED medication?*
  • Do you prefer a medication that works for a shorter time (4-6 hours) or a longer time (up to 36 hours)?*
  • Do you have a preference for taking a pill daily or only as needed?*
  • Are you comfortable with a medication that requires planning (taken 30-60 minutes before activity)?*
  • Do you have any concerns about side effects?*

  • Your Medication Choices

    To help you choose the right ED medication, here’s a brief overview:

    Daily Tadalafil (Cialis) is a low-dose (5mg) pill taken every day, offering spontaneity without planning, as it keeps you ready anytime and lasts up to 36 hours per dose. It’s ideal if you prefer frequent sexual activity (several times a week) or dislike timing doses.

    On-Demand Tadalafil (Cialis) is a higher-dose pill taken only when needed, working within 30-60 minutes and lasting up to 36 hours, perfect for those who want flexibility over a longer window.

    Sildenafil (Viagra) is taken as needed, about 30-60 minutes before activity, and lasts 4-6 hours, best for those who plan sexual activity and prefer a shorter-acting option. Your answers to the following questions will help our clinicians recommend the option that fits your lifestyle and health needs.

  • Based on the above information and your answers, which do you feel would best help you with your erectile issues?*

  • My Products

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    EDCheck Telehealth Consultation and Prescription Product Image
    EDCheck Telehealth Consultation and Prescription
    $65.00 AUD$65.00AUD
      
    Total
    $0.00 AUD$0.00AUD
    Debit or Credit Card

  • Assignment of Medicare Benefit (Bulk Billing)
    I understand that Men's Health GP (or the treating practitioner) intends to bulk bill the Medicare benefit for the professional services provided during this consultation.

    By submitting this form I:

    - Assign my right to the Medicare benefit to the health practitioner.
    - Agree to accept the relevant Medicare benefit as full payment for the service.
    - Understand that a copy of the completed Assignment of Benefit form (or a summary of the service) will be provided to me electronically via my nominated email address.

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