1.1 – Personal Details
1.2 – Contact Details
1.3 – Medicare Details
Sexual Function: Patient Eligibility Form
About Your Concern
Medical Information
PATIENT INFORMED CONSENT FORM

Sexual Function Programme

1. Introduction

This Informed Consent Form (‘Form’) documents your voluntary agreement to proceed with treatment under the Sexual Function Programme (‘Programme’) at Optivital Health, prepared in accordance with AHPRA, TGA, and Privacy Act 1988 (Cth) requirements. By signing, you confirm you have received sufficient information, had your questions answered, and are consenting freely and voluntarily.

2. About the Programme

This Programme provides medically supervised assessment and treatment of male sexual dysfunction via telehealth, including erectile dysfunction (ED), premature ejaculation (PE), and reduced libido. Medications commonly prescribed include PDE5 inhibitors (e.g., sildenafil, tadalafil), topical or oral agents for PE, and, where indicated, testosterone-based therapies. Dosage and formulation are determined at consultation.

3. Regulatory Status

By signing this Form, you acknowledge the regulatory status of any compounded formulation prescribed; that the clinical rationale has been explained; and that you consent to proceed voluntarily.

4. Material Risks and Possible Side Effects

4.1 PDE5 Inhibitors (e.g., sildenafil, tadalafil)

  • Headache, facial flushing, nasal congestion, or dyspepsia;
  • Transient visual disturbances or altered colour perception;
  • Hypotension – risk significantly increased with nitrate medications. PDE5 inhibitors are absolutely contraindicated with nitrates; and
  • Rare risk of priapism (erection exceeding 4 hours) – seek emergency care immediately.

4.2 Cardiovascular Considerations

Sexual activity and PDE5 inhibitors place demands on the cardiovascular system. Disclose any history of significant heart disease, recent myocardial infarction or stroke, or medical advice to avoid sexual activity before treatment commences.

4.3 Premature Ejaculation Treatments

  • Topical anaesthetics may cause temporary reduced sensation for both partners; and
  • SSRI-based treatments may cause nausea, mood changes, or delayed ejaculation, and must not be stopped abruptly.

5. Monitoring Requirements

  • A check-in consultation is scheduled 1 week post-consultation to assess response and side effects;
  • A 30-day follow-up prompt is sent to offer a follow-up consultation if required;
  • Medication check-in is scheduled 2 weeks before projected supply exhaustion; and
  • Ongoing follow-up is patient-initiated (PRN) unless your practitioner advises otherwise.

6. Alternative Treatments

Alternatives include lifestyle modification (cardiovascular fitness, alcohol and tobacco reduction), psychological or relationship counselling, vacuum erection devices, and, for ED not responding to pharmacotherapy, urological referral for intracavernosal injection therapy or surgical options.

7. Patient Responsibilities

  • Disclose all current medications, particularly nitrates and antihypertensives, before and during treatment;
  • Report any side effects, including cardiovascular symptoms, promptly;
  • Use medications strictly as directed and do not exceed prescribed doses; and
  • Inform your GP that you are receiving treatment under this Programme.

8. Telehealth Consultations

  • You are responsible for ensuring you have a stable internet connection, a functioning device with a camera and microphone, and are in a private location at the time of your consultation;
  • If a technical failure occurs that prevents the consultation from proceeding, our team will contact you to reschedule at the earliest available time;
  • Telehealth consultations do not permit physical examination. Your treating practitioner will rely on your self-reported symptoms, uploaded documents, and pathology results. You must disclose all relevant information accurately; and
  • If at any point your condition requires in-person assessment or emergency care, you must present to an appropriate healthcare facility immediately.

9. Payment and Fees

  • Consultation fees are due at the time of booking or as otherwise communicated by Optivital Health. Fees are non-refundable once a consultation has been attended;
  • Medication costs are separate from consultation fees and are invoiced at the time of prescription processing. Costs vary by formulation and dosage as determined at each consultation; and
  • Some pathology tests required under this Programme may not be bulk-billable and may incur an out-of-pocket fee. Your clinical team will advise you in advance where this applies.

10. Cancellations and Rescheduling

  • You must provide at least 48 hours’ notice to cancel or reschedule a consultation. Notice can be provided by replying to your appointment confirmation email or by contacting the clinic directly;
  • Cancellations with less than 48 hours’ notice, or failure to attend without notice (no-show), may incur a cancellation fee as communicated in your booking confirmation;
  • Where a consultation is cancelled by Optivital Health (e.g., due to practitioner unavailability), you will be offered a rescheduled appointment at no additional cost; and
  • Repeated cancellations or no-shows may affect your continued participation in the Programme at the discretion of the treating practitioner.

11. Privacy

Your personal and health information is collected, used, and stored in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles (APPs). It is used to provide clinical care, facilitate prescription processing and dispensing, and support continuity of care. Your information will not be disclosed to third parties without your consent except as required by law (e.g., mandatory reporting obligations, court orders, or TGA reporting requirements under applicable Authorised Prescriber conditions).

You have the right to access and correct your personal information held by Optivital Health. To make a request, contact the clinic directly. Our full Privacy Policy is available on request.

12. Right to Withdraw Consent

You may withdraw your consent to the Sexual Function Programme at any time without penalty by notifying your treating practitioner. Withdrawal will result in cessation of your treatment plan. Where clinically appropriate, your practitioner will advise on any recommended transition or tapering protocol. Withdrawal does not entitle you to a refund of consultation or medication costs already incurred.

13. Patient Declaration

I declare that I have read and understood this Form in full; my questions have been answered to my satisfaction; I understand the nature, purpose, risks, and limitations of the Sexual Function Programme; I have disclosed my full medical history and all current medications and supplements; I understand my responsibilities including attendance, monitoring, and payment obligations; and I am consenting freely and voluntarily to proceed at Optivital Health.

3.1 – Confirmation
Confirm you are ready to finalise and submit this form to your practitioner.