Intake Form

Today's Date

Patient Name

Date Of Birth

Phone Number

Email Address

Address

Occupation

Driver's License State or ID

Are You Currently Taking Any Medications?

Yes No

Emergency Contact Name

Emergency Contact's Phone Number

Emergency Contact's Relationship To Patient?

What are You Interested in?

Erectile Dysfunction (ED) Peyronies (Curvature of the Penis) Weight Loss - No Excercise Program Bio Identical Hormone Replacement

What treatments have you already done?

If so, how did it work?:

Did you experience any side effects?:

Medical Conditions: Please List All Medical Problems:

Please List Current Medications / Supplements :

Please Describe Surgical History:

Privacy Notice (HIPPA)

I Agree I Disagree

Informed Patient Consent: By Typing Your Name Below You Agree To The Informed Patient Consent

What Location are you interested in?

Norwich Connecticut Falmouth Massachusetts Lekki area Lagos Nigeria

Lekki, NIGERIA