Basic Information Let’s start with some basic information What is your main concern relating to erectile dysfunction? *I have difficulty starting a penile erectionI have difficulty maintaining my erectionPremature ejaculationOther---------------------------------------Please explain your concern *How often do you experience ED symptoms? *Every time I engage in sexual activityOccasionallyRarelyWhen did your symptoms start? *Less than 6 months agoMore than 6 months agoLonger than one yearAre you prone to experiencing ED related symptoms in the following conditions? *When I smokeWhen I drink alcoholWhen I experience stress or anxietyWhen I take certain drugs medications or supplementsOther---------------------------------------How often do you smoke? *FrequentlyOccasionallyRarelyHow often do you drink? *FrequentlyOccasionallyRarelyPlease describe your stressors: *Please describe which drugs, medications or supplements trigger your symptoms: *Please explain below: *How often do you engage in sexual activity? *Rarely - less than once a monthOccasionally - 2-3 times a monthWeekly - 1-2 times a weekFrequently - 3-4 times a weekVery frequently - almost dailyDo you currently have or have had any of the following conditions? *Cardiovascular diseasesBlood disordersLung or pulmonary diseasesGastrointestinal disordersPsychological disordersNeurological or musculoskeletal disordersUrinary or reproductive disordersHormonal imbalanceMy condition is not listedI do not have any other conditions---------------------------------------Please describe the nature of your cardiovascular condition below: *Please describe which blood disorder(s) you have: *Please describe the nature of your pulmonary condition below: *Please describe your GI condition below: *Please describe the nature of your psychological disorder: *Please describe which neurological or musculoskeletal condition you have: *Please describe the nature of your urinary/reproductive disorder below: *Please describe the nature of your hormonal imbalance: *Please describe the unlisted condition *Please describe your condition, when it began, and any treatments you are currently using.Do you take nitroglycerine? *YesNoDo you experience spontaneous erections (at night and/or when you wake up) *YesNoHave you had major trauma, significant weight loss, surgeries or hospitalizations in the past six months? *Recent trauma, illness, significant weight changes, surgeries, or hospitalizations can impact your overall health and may affect which treatments are safe and appropriate. This information helps the physician identify underlying factors and guide your care responsibly.YesNoPlease specify details *Have you ever taken medication for erectile dysfunction before? *YesNo(Select as many as you like)If yes, then are you looking to *Change medicationChange prescriptionNoneWhat is your current medication and prescribed dose? *Are you currently taking any other medications? *Current medications may interact with hair loss treatments or affect their safety. Listing all medications you take helps the physician avoid contraindications and choose the most appropriate treatment for you.YesNo---------------------------------------Please specify the medication *Please name the medication, which condition it is for, dosage/prescription, frequency and any side effects you may be experiencingDo you have any known allergies? *Allergies can affect which medications are safe for you.YesNo---------------------------------------Please specify the allergen / reaction *List the allergen, your reaction, and any treatment received so the physician can ensure safe prescribing.Do you consume alcohol, use tobacco products, or use any recreational drugs? *Alcohol, tobacco, and recreational drug use can affect sexual health and may interact with certain medications. This information helps the physician assess contributing factors and ensure safe treatment planning.YesNo---------------------------------------Please specify the drug(s) *Which drug and frequencyWhat is your current weight (lbs or kgs)? *What is your most recent blood pressure reading? *Must be within last 6 monthsLow blood pressure (below 90/60)Normal (90/60 to 119/79)Slightly elevated (120–129 / under 80)High blood pressure – Stage 1 (130–139 / 80–89)Very High blood pressure – Stage 2 (140+ / 90+)I’m not sure / I don’t check it regularlyHave you had blood work done in the last one year? *Recent blood work provides key information about your overall health and can identify conditions that may affect treatment safety or effectiveness. If your blood work is outdated, the physician may request updated tests to ensure an accurate and safe assessment.YesNo---------------------------------------If yes, then was there anything abnormal in the report? *YesNoPlease describe what was abnormal *Is there any additional medical information, questions or requests for the doctor that you’d like to include? *How long would you like your ED medication to last? *Different ED medications vary in how long they remain effective. Understanding your preferred duration helps the physician select the most suitable medication to match your needs and treatment goals.Short duration (approximately 4 hours) - for targeted durationModerate duration (approximately 4-6 hours) - for balanced flexibilityExtended duration (approximately 36 hours) - allows spontaneity throughout the dayI am not sure please provide me a FREE consultation registration form GenderMaleFemalePrefer not to sayDo you have any other form of insurance? *YESNOOptional Combination Therapy *I am interested in information about adjunct SONICWAVE therapy, which may be used alongside PDE-5 medications to support treatment outcomes.YESNOPlease upload a clear full-body photo for safety and compliance *Telehealth standard of care - This step helps our clinicians ensure the information you’ve provided matches your profile and supports safe prescribing. Your photo remains private and protected at all times. Your information is encrypted and stored securely under PHIPA and PIPEDA guidelines.Drag and Drop (or) Choose FilesPlease provide a clear photo of your valid Ontario Health Card *Our team uses this only to confirm your identity and ensure you receive any OHIP-covered benefits you may be eligible for. Your information remains private and fully protected.Drag and Drop (or) Choose FilesPlease upload a photo of a valid Ontario government-issued ID (Driver’s License, Photo Card or Passport) *This helps us verify your identity and maintain a safe, compliant clinical process. Your ID is used only for verification and is securely stored under Ontario privacy regulations.Drag and Drop (or) Choose FilesWhat happens next… 1. Payment Processing: The CA $40 telehealth assessment fee is collected upfront to begin the assessment. 2. File Review: Your intake is securely reviewed and prepared by the care coordination team. 3. Physician Assessment and Prescription: A licensed physician reviews the assessment to determine if treatment is appropriate. If approved, a prescription is issued. 4. Medication Fulfillment: Medication is dispensed by a licensed pharmacy and delivered discreetly. 5. Ongoing Support: Support is available for follow-ups, renewals, and treatment adjustments.Fees & Payment Notice .... A $40 Telehealth assessment fee applies to all new visits and renewals. This is not a physician fee. It covers Rumini’s secure clinical intake review, care coordination, administrative processing, access to our virtual care platform, and free, discreet delivery of your medication once prescribed. This fee supports the convenience and privacy of fast, online care, it is non-refundable once the assessment has been reviewed. ED treatments start at $4–$12 per tablet The final cost will vary based on medication type and strength. Medication is billed separately once your prescription is approved.Consent - By clicking Submit, you accept our Terms of Use and Privacy Policy, (accessible on www.rumini.ca) and provide consent for Rumini to securely collect and process your information through virtual care. You also confirm that all information provided is true, accurate, and complete to the best of your knowledge.Rigister Get Started First Name: Last Name: Email: Phone Number: Primary Concern Select...Difficulty initiating a penile erectionDifficulty maintaining a penile erectionPremature ejaculationReduced rigidityOther Medication Preference Select...Sildenafil (Viagra®)Vardenafil (Levitra®)Tadalafil (Cialis®)Not sure – I’d like guidance
