EDCheck Patient Registration Form

Men's Telehealth Patient Registration Form

Please fill out this form to register for our telehealth service. We provide consultations and prescriptions for medications such as Viagra and Cialis.
First Name
Last Name
Email Address*
example@example.com
Do you have a Medicare Card?

YesNo
What is your Medicare Card Number?
What is your Medicare Card Line Number? (ie. What number are you on the 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
What is your Individual Health Identifier (IHI)?
Do you have a regular GP?*

YesNo
Would you like us to let your GP know you have consulted with us and advise them of any medications we have prescribed?*

YesNo
What is your GPs name?*
What clinic do they work at? *
Mobile Phone Number*
Residential Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*

DayMonthYear
Date
Do you currently have any of the following medical conditions? (Select all that apply. Leave blank if none apply.)

Heart DiseaseRecent Heart Attack (in the last 6 months)Uncontroled High Blood PressureStrokeSevere Liver DiseaseSevere Kidney Disease
Do you currently take any of the following medications? (Select all that apply. Leave blank if none apply.)

Nitrates (e.g., nitroglycerin)Riociguat (eg. Adempas)Recreational drugs (e.g., poppers),
Do you have any allergies to medications?*

NoYes
Please list the medications you are allergic to
Have you used any of the following ED Medications before?

Sildenafil (Viagra)Tadalafil (Cialis)Vardenafil (Levitra)Avanafil (Spedra)
Did you experience any side effects?
ED Assessment
How long have you experienced issues with your erections?*

Less than 3 months3-6 months6-12 monthsOver 1 year
How often do you experience difficulty achieving or maintaining an erection?*

Rarely (less than 25% of the time)Sometimes (25-50%)Often (50-75%)Always (75-100%)
Do you wake up with morning erections?*

Yes, regularlyYes, occasionallyNo
Do you believe your erectile issues is related to any of the following?*

Stress or anxietyRelationship issuesDiabetesHigh blood pressureSmokingExcessive alcohol useOtherNone of these
Treatment Preferences
How often do you anticipate needing ED medication?*

A few times a week or moreOnce a week or lessIt varies
Do you prefer a medication that works for a shorter time (4-6 hours) or a longer time (up to 36 hours)?*

Shorter (taken right before)Longer (more flexibility)No preference
Do you have a preference for taking a pill daily or only as needed?*

DailyAs neededNo preference
Are you comfortable with a medication that requires planning (taken 30-60 minutes before activity)?*

YesNoNo preference
Do you have any concerns about side effects?*

YesNo
What are you concerns?
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?*

SildenafilDaily TadalafilOn Demand TadalfilNot sure - will wait to discuss with the doctor
Have you attended a Vasectomy Australia clinic in person for a procedure or consultation in the last 12 months?*

NoYes

I confirm that my answers are accurate and understand that a clinician will review this form to determine my eligibility for treatment. I consent to telehealth services.*

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Men's Telehealth Patient Registration Form

ED Assessment

Treatment Preferences