Your First Name *

Your Last Name *

Verify Your Cell Phone Number *

Best Email Address That You Read *

Zip Code *

Select The Issue/s You Have!

Weight Loss

Erectile dysfunction

Both

What Are Your Goals For This Treatment? Select all that apply

Has Previous Surgical Work Been Done On These Areas? Select one

Yes

No

It's Complicated

On Those Days, How Rigorous Is Your Activity/Exercise? Select One:

NA

Light

Moderate

Intense

What Is Your Preferred Payment Method For This Treatment? Select One:

Cash

Debit

Credit Card

Current Weight

Current Medication or Supplements

Chief Complaint

How many years ago was the VERY FIRST time you had trouble getting an erection? (the average answer is 10 years, YOU MUST PICK ONE)!

If you try to have sex without taking an Ed medication to help, what % of hardness can you get?

Are you cicumcised?

Yes

No

If no, does foreskin retract easily?

Yes

No

What surgeries have you had?

Have you ever been diagnosed with or currently have any of the following

Smokers?

Years?

Packs per day?

Peyronies/curvature of the penis? (If so, what degree of curve?)

Any other medical problems:

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