First Name:

Email Address:

Phone Number:

What are your primary concerns? (Select all that apply)
Reduced sensitivity or pleasureDecreased confidence in intimacyVaginal dryness or discomfortPain or burning sensation during intercourseWeak pelvic floor or lack of tightnessDecreased libido or interest in intimacyUrinary incontinence or leakageLoss of intimacy or connection in my relationshipOther:

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 pelvic exercises (Kegels, etc.)Yes, I’ve used lubricants or other productsYes, I’ve tried hormonal therapyYes, I’ve tried other treatments (please specify):

If you selected "Other treatments," please specify:

How important is improving your intimate health 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 flag.