Spontan

Spontan Request Details

Important: Spontan is designed for the treatment of erectile dysfunction. A prescription is required and all requests are reviewed by an Australian-registered doctor. Your suitability will be assessed based on your health information.

Why are you requesting Spontan? *

Erectile dysfunction (diagnosed) Occasional performance issues Doctor recommended Other

Have you tried any other treatments for erectile dysfunction? *

Yes, oral medication Yes, other treatments No, this is my first treatment

If yes, please describe previous treatments and results.

Do you have a current prescription for erectile dysfunction medication? *

Yes, from my GP or specialist No, I am seeking a new prescription

Your Health Background

Privacy Notice: The information you share will be reviewed by a licensed doctor to assess your suitability for Spontan. It will be securely stored and not shared without your consent.

Do you have any of the following health conditions? *

Heart disease High or low blood pressure Nasal issues (chronic congestion, surgery, etc.) Other significant health conditions Other

Do you experience frequent headaches, chest pain, or dizziness? *

Yes No

Please provide additional details about any health conditions.

Medications & Allergies

Important: Knowing your current medications and allergies helps prevent harmful interactions or side effects.

Are you currently taking any medications? *

No Yes

Please list any medications you are currently taking.

Do you have any known allergies (especially to nasal sprays or ED medications)?

Consent & Acknowledgement

Final Acknowledgement: I confirm that the information I have provided is accurate. I understand that this service does not replace a face-to-face medical consultation and that I may be contacted for further details if required.

Acknowledgement of Accurate Details *

I declare that the personal information provided is true and correct, and acknowledge that providing false or incomplete details may result in delays or denial of prescriptions, documentation, or appointments.

Signature *

Confirm Your Details

We’ll use your email to match your booking. Please enter your Medicare number to confirm.

Email *

Medicare Number *

Medicare Reference *

Fast & Simple Spontan Request