Thank You for Reaching Out!

We’ve received your information and are excited to help you take the next step toward feeling confident again. To ensure we provide the best possible care tailored to your needs, we invite you to take just 30 seconds to fill out a quick survey.

By sharing a little more about yourself, you’ll help us understand your unique situation, so we can customize our approach to deliver the best results for you.

INSTRUCTIONS

Each question has 5 possible responses. Choose the number that best describes your own situation. Select only 1 answer for each question.

Over the past 6 months:

1. How do you rate your confidence that you could keep an erection?(Required)
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?(Required)
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?(Required)
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?(Required)
5. When you attempted sexual intercourse, how often was it satisfactory for you?(Required)
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We’re committed to your well-being, and this survey will help us ensure you receive the personalized care you deserve.