Name:

Email Address:

Phone Number:

What are your primary concerns? (Select all that apply)
Decreased sexual performanceDifficulty maintaining an erectionReduced sensitivity or pleasureDecreased stamina or endurancePerformance anxiety or confidence issuesLack of spontaneity in intimacyDecreased morning or spontaneous erectionsGeneral loss of vitality and energyIncreased stress affecting performanceOther:

How long have you been experiencing these concerns?
Less than 6 months6 months to 1 year1-3 yearsMore than 3 years

Have you tried any treatments before?
No, this is my first time seeking helpYes, I’ve tried over-the-counter supplementsYes, I’ve used prescription medications (Viagra, Cialis, etc.)Yes, I’ve tried other treatments (please specify):

If you selected "Other treatments," please specify:

How important is improving your performance to you?
Very important – this is affecting my confidence and relationshipsImportant – I’d like to improve but it’s not urgentSomewhat important – I’m just exploring optionsNot important – just gathering information

Are you currently taking any medications?
NoYes (please list below)

What is your age group?
18-3031-4041-5051-6061+

Would you like us to contact you to discuss solutions?
Yes, I’d like a free consultationNo, I’d just like more information for now

Please prove you are human by selecting the car.