Get a Prescription for Vaginal Dryness

- Step 1 of 6

Name *

First

Last

Date of Birth *

Email *

Address *

Select Pharmacy to where prescriptions should be sent. Select "other" if you can't find your pharmacy *

1. Please confirm you are using this service for yourself *

2. Please share your birth gender *

Male
Female

3. Please share your age with us *

4. Are you pregnant or breastfeeding? *

5. Have you ever had a diagnosis of breast cancer? *

Please share more information with us *

6. Have you ever had a diagnosis of Endometrial cancer? *

Please share more information with us *

7. Have you ever had a diagnosis of ovarian cancer? *

Please share more information with us *

8. Have you experienced any unexpected bleeding in the last 12 months? *

Please share more information with us *

9. Has your vaginal discharge increased? *

Please share more information with us *

10. Do you have vaginal symptoms at the moment? *

Please share more information with us *

11. If you have symptoms, which of these apply to you? *

Vaginal dryness
Feeling itchy
Irritation, feeling sore or burning
Pain during sex
None of the above

12. If you have symptoms, how long have you experienced them? *

less than 3 months
More than 3 months

13. Do you have any of the following urinary symptoms? *

Pain when urinating
Feeling urgency to urinate often
Reoccurring urine infections
None of the above

14. Have you had a cervical smear test? (under age 65) *

Yes
No
No- I am over 65

15. Have you ever had a mammogram? (between ages 50-69) *

Yes
No
No- I am not applicable

16. Are there any other medical conditions you would like to share with us? *

Please share more information with us *

17. Have you ever had any operations? *

Please share more information with us *

18. Have you ever used vagifem before? *

19. Are you using any other medications for vaginal dryness? *

Please share more information with us *

20. Do you take any prescription medication? *

Please share more information with us *

21. Do you have any allergies? *

Please share more information with us *

22. Please confirm that you have answered all questions with complete honesty *

Yes - I confirm that I have answered all questions with complete honesty

Price

Total Amount: 25 €

Pay with a Debit or Credit Card *

Card

Name on Card