Online Consultation for Trimix Injection

Consultation Form Once you have provided the information below we can email you an information pack to pass onto your doctor on how to prescribe the most appropriate strength of Trimix for you.
First Name *
Last Name *
Contact Phone Number *
Email *
Postal Street Address *
Suburb *
Postcode *
State *
Date Of Birth *
Do you have any allergies/sensitivities? If yes, what are they? *
Are you currently taking any medications? If yes, please list them all. *
Do you have any current or past health conditions? If yes, please specify. *
Have you previously had prostate surgery?
What medication including strength have you tried in the past to treat ED? *
Please rate the response from 0 to 10 (0 being no reposne to 10 being full response) for the medication listed above.
Doctor's Email So we can contact your doctor to help them prescribe Trimix for you
Important information: Once our ED consultant has reviewed your responses he will email you an information pack for you to print out and bring to your doctor to have your doctor prescribe it for you. Once you have the script please click on the Prescription Ordering tab at the top of the page to place an order. Alternatively you can fax it to us on 02-66862257 or email it to reception@custommedicine.com.au