PE Survey - Gambit

Step 1 of 18

Getting Started with your PE Visit

For our healthcare practitioners to prescribe medication, we need to know a few things about your health and medical history. Answer this short questionnaire and a licensed healthcare provider will assess your case and reach out to you. Your progress is automatically saved. You will be required to upload the following. Please have them ready for faster completion of the intake questionnaire:
- Government ID
- Provincial health card
- Private insurance card (if any)
- Selfie for identification purposes

By proceeding, you agree that you:(Required)

Are biologically male at birth

Agree to our Terms of Service and Privacy Policy.

Are completing this form for yourself and will answer the questions accurately and completely to your best ability

Will disclose and consent to have stored the information of any prescription medication you currently take and any serious illnesses or surgeries you have had.

Understand that premature ejaculation medication is a last resort treatment for when alternative means have proven ineffective. Premature ejaculation (PE) is best treated by maintaining a healthy diet and a regular pelvic exercise routine as well as the regular use of condoms. PE may also be caused by anxiety associated with sex or early sexual experiences.

By proceeding with the intake form, you accept any risks involved in the consultation, diagnosis and treatment regime for any contributing conditions and in the treatment we prescribe. We strongly recommend you have your primary care provider assess you for the possibility of pre-existing conditions prior to using our service.

Which medication do you prefer?

Don't worry too much about your choice at this stage. Your doctor will ensure you get the right treatment.

Paroxetine Daily Learn More

Which medication do you prefer? Paroxetine as Needed (from 19.56/mo)

Paroxetine as Needed Learn More

Which medication do you prefer? Delay Gel (from $60.00/bottle)

Delay Gel Learn More

Untitled

Choose Later (Let our medical practitioners guide you)

Safety Information

Safety Information(Required)

I acknowledge that I have read and understood the important safety information of Paroxetine Daily.

Safety Information(Required)

I acknowledge that I have read and understood the important safety information of Paroxetine as Needed.

Safety Information(Required)

I acknowledge that I have read and understood the important safety information of Delay Gel.

Do you climax earlier than you or your partner would like?(Required)

Yes

How long does it typically take for you to climax?(Required)

Before sexual activity

Less than 1 minute

1 to 3 minutes

3 to 5 minutes

5 to 10 minutes

More than 10 minutes

How often do you engage in sexual activity per week?(Required)

How much supply would you like to be prescribed for?(Required)

3 months

6 months

12 months

Do you experience any difficulty getting or maintaining an erection for sexual activity?(Required)

Trouble getting an erection

Trouble maintaining an erection

Both

None

What is your weight and height?(Required)

Weight( in lb)(Required)

Please enter a number from 1 to 300.

Height (feet)(Required)

Please enter a number from 1 to 300.

Height (Inches)(Required)

Please enter a number from 1 to 300.

Weight( in kg)(Required)

Please enter a number from 1 to 300.

Height (in cm)(Required)

Please enter a number from 1 to 300.

Pant size: Inches

Please enter a number from 1 to 300.

Please list any prescription medications, OTC medication, herbal products or natural supplements that you are currently taking on a regular or as-needed basis.(Required)

Please list the names and why you take each medication

Please list any allergies to medications or other substances(Required)

If you have a photo of your pharmacy medication record, you can upload it here

Drop files here or

Accepted file types: tiff, jpeg, jpg, gif, png, pdf, Max. file size: 5 MB.

How familiar are you with Premature Ejaculation (PE) treatments?(Required)

I have taken PE treatments in the recent past and now I want to start again

This is my first time treating PE symptoms

Tell us about the PE treatment you recently used. Please mention the name, dose, and your satisfaction with the treatment.(Required)

Include any treatment, whether it is a prescription or over-the-counter supplement

Please check all of the following symptoms you experience:(Required)

Chest pain or severe shortness of breadth with sexual activity

Chest pain or severe shortness of breath when climbing up 2 flights of stairs or walking a few blocks

Unexplained fainting or dizziness

Abnormal heart beat or rhythm

None of the above symptoms apply to me

Please explain more briefly about the symptoms:

Have you had any surgeries or hospitalizations?(Required)

Yes

Please state the date and the reason(s) you were underwent surgery or were hospitalized.(Required)

Have you been diagnosed with any chronic medical conditions? Check all that apply(Required)

Mental health diagnosis

Epilepsy or seizures

Diabetes

Kidney disease

Liver conditions

Other conditions

I have no known medical conditions

Which mental health condition have you been diagnosed with?(Required)

Anxiety

Depression

Bipolar

Other

Please tell us more in your own words (Other conditions).(Required)

Please describe your medical condition in your own words (Epilepsy or seizures).(Required)

What are your blood sugar (glucose) measurements? Please list your fasting levels (before eating or when you wake up) and after-meals (wait 2 hours).(Required)

If you measured your A1C levels within 2 months, please record date and measurement.

Please describe your medical condition in your own words (Kidney disease).(Required)

Please describe your medical condition in your own words (Liver conditions).(Required)

Do you smoke cigarettes, electronic cigarettes (vapes), or other nicotine/tobacco products?(Required)

Yes

Yes, but I want to quit

Please tell us a bit more about what products you smoke. Check all that apply.(Required)

Cigarettes

Vapes

Shisha (hookah)

Cigar or cigarillo

Chew tobacco

Do you feel addicted or that your smoking is out of control?(Required)

Yes, and I am ready to quit completely

Yes, but I am not ready to quit completely

No, I am happy with my smoking

Do you drink alcohol?(Required)

Yes

Yes, but I want to quit

Tell us more about yourself. Our clinicians and staff will use the following to reach out to you about your health and assessment information.

All personal information is kept confidential and completely encrypted, disclosed only to Gambit's Allied Health Team for clinical services and to contact you regarding your health concerns.
Gambit follows strict PIPEDA guidelines and is compliant with digital security standards.
If you have any questions or would like to reach out to our staff, please don't hesitate to contact us at +1 (519) 715-8997 or by emailing support@getgambit.ca.

Name(Required)

First Last

Date of birth(Required)

MM slash DD slash YYYY

Email(Required)

Password(Required)

Enter Password Confirm Password

Phone(Required)

Which province do you reside in?(Required)

Upload a photo of government issued ID (e.g. drivers license). Canadian Telemedicine Law requires us to verify your identification before we can prescribe any medication. You can always do this later if you don't have your ID with you right now.

By uploading ID, you consent to us collecting your identifying documents and personal information, for the purposes of (i) authenticating your identifying documents, and (ii) complying with the law governing pharmacies and telemedicine. You acknowledge reading our Privacy Policy, which contains full details on these purposes

256-BIT TLS SECURITY Please make sure
Your ID is valid and within the frame
Your information is clearly visible

Drop files here or

Accepted file types: tiff, jpeg, jpg, gif, png, pdf, Max. file size: 5 MB.

Is your address on your ID your current address?

Yes

Please enter your current address:(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Do you have a provincial health card? (If you don't have it with you right now, don't worry! Our team will reach out to you for this later)

256-BIT TLS SECURITY

Yes

I do not have a provincial health card.

Front of health card:(Required)

Drop files here or

Accepted file types: tiff, jpeg, jpg, gif, png, pdf, Max. file size: 5 MB.

Back of health card:(Required)

Drop files here or

Accepted file types: tiff, jpeg, jpg, gif, png, pdf, Max. file size: 5 MB.

Please provide the health card number as it appears on the card

Please upload a selfie, ensuring your face is fully within frame, clearly visible, and not filtered in any way (If you're having a bad hair day, don't worry about it! You can always do this later)

256-BIT TLS SECURITY Please make sure your face and shoulders are visible and well-lit.

Drop files here or

Accepted file types: tiff, jpeg, jpg, gif, png, pdf, Max. file size: 5 MB.

Do you have coverage for medications through a private insurance plan?(Required)

256-BIT TLS SECURITY Please make sure
Your card is valid
Within the frame
Your information is clearly visible

Yes

Front of insurance card:

Drop files here or

Accepted file types: jpg, png, tiff, jpeg, Max. file size: 5 MB.

Back of insurance card:

Drop files here or

Accepted file types: jpg, png, tiff, jpeg, Max. file size: 5 MB.

Do you have additional coverage for medications through a 2nd private insurance plan?(Required)

Yes

Front of insurance card:

Drop files here or

Accepted file types: jpg, png, tiff, jpeg, Max. file size: 5 MB.

Back of insurance card:

Drop files here or

Accepted file types: jpg, png, tiff, jpeg, Max. file size: 5 MB.

Summary

Your Treatment If Prescribed

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$39.12 - $78.24 for 3 months

Price:

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$78.24 - $117.36 for 6 months

Price:

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$117.36 - $156.48 for 1 year

Price:

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$78.24 - $117.36 for 3 months

Price:

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$156.48 - $312.96 for 6 months

Price:

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$312.96 - $391.20 for 1 year

Price:

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$117.36 - $234.72 for 3 months

Price:

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$234.72 - $469.44 for 6 months

Price:

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$469.44 - $625.92 for 1 year

Price:

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$156.48 - $312.96 for 3 months

Price:

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$312.96 - $625.92 for 6 months

Price:

Paroxetine 10mg

Paroxetine 10mg
Adjustable once prescribed

$625.92 - $782.40 for 1 year

Price:

Paroxetine as Needed