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Am I a candidate?
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(512) 943-6945
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For Women
O-Shot®
diVa®
FemiWave™
Vampire Breast Lift®
Vampire Wing Lift®
Hormone Replacement
Intimate Bleaching
For Men
GAINSWave®
P-Shot®
Scrotox
Hormone Replacement
Intimate Bleaching
Back
Decreased Nipple Sensation
Difficulty Reaching Orgasm
Erectile Dysfunction
Peyronie’s Disease
Premature Ejaculation
Hormone Replacement Therapy
Vaginal Dryness
Low Sex Drive
Urinary Incontinence
Balanitis Xerotica Obliterans (BXO)
Lichen Sclerosus
Labial Discoloration & Shrinkage
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Am I a candidate?
Find out if you're a candidate for our treatments or services.
Am I a candidate?
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Am I a Candidate?
Am I a candidate?
Gender?
*
Male
Female
Other
Age Range?
*
18-29 years old
30-39 years old
40-49 years old
50-64 years old
65 years or older
Is your current sex life satisfying?
Yes
No
What are you experiencing? (male)
*
Low Libido
Decreased Sensitivity
Decrease in Performance
Inability to Have an Orgasm
Painful Intercourse
Decreased Sex Drive
Premature Ejaculation
Abnormal Penile Curvature/Peyronie's Disease
Erectile Dysfunction
BXO Penis
Urinary Incontinence
Interstitial Cystitis
Decreased Nipple Sensitivity
Abnormal Skin Changes
Dry, Wrinkled Skin
Weight Gain
Hair Loss/Breakage
General Body Image
Fatigue
Mood Changes
Decreased Mental Ability/Focus
Hot Flashes/Night Sweats
Sleep Problems
Always Cold
What are you experiencing? (female)
*
Low Libido
Vaginal Dryness
Decreased Sex Drive
Decreased Sensitivity
Inability to have an Orgasm
Lichen Sclerosus
Painful Intercourse
Urinary Incontinence
Interstitial Cystitis
Decreased Nipple Sensitivity
Sagging Breasts
Abnormal Skin Changes
Weight Gain
General Body Image
Dry, Wrinkled Skin
Hair Loss/Breakage
Fatigue
Mood Changes
Decreased Mental Ability/Focus
Hot Flashes/Night Sweats
Sleep Problems
Always Cold
What are you experiencing? (other)
*
Low Libido
Decreased Sensitivity
Decrease in Performance
Decreased Sex Drive
Painful Intercourse
Inability to Have an Orgasm
Decreased Nipple Sensitivity
Vaginal Dryness
Sagging Breasts
Erectile Dysfunction
Abnormal Penile Curvature/Peyronie's Disease
Premature Ejaculation
Interstitial Cystitis
Urinary Incontinence
Abnormal Skin Changes
Weight Gain
General Body Image
Dry, Wrinkled Skin
Hair Loss/Breakage
Fatigue
Mood Changes
Decreased Mental Ability/Focus
Hot Flashes/Night Sweats
Sleep Problems
Always Cold
How long have you been experiencing these issues?
*
What is your current relationship status?
*
Single
In a Relationship
Married
Separated
Divorced
Widowed
Have you tried or are you trying any other treatments?
*
Yes
No
What treatments have you tried or are you trying? (ex: Viagra or Cialis)
Do you have or have you had any of the following?
*
Diabetes
Heart Disease
High Blood Pressure
Depression/Anxiety
Prostate Cancer/Surgery
Breast Cancer
Penile Implant
Dialysis
None
What insulin do you currently use?
What Beta Blockers, if any, do you currently use?
What SSRIs, if any, do you currently use?
Treatments Interested In
diVa
O-Shot
FemiWAVE
Hormone Replacement Therapy (BioTE)
Intimate Bleaching
Vampire Breast Lift
Vampire Wing Lift
Other or Not Listed
Treatments Interested In
GAINSWave
P-Shot
Scrotox
EvexiPEL® Hormone Replacement
Intimate Bleaching
Other or Not Listed
Is there anything else that you would like us to know?
Name
*
First
Last
Phone
*
Email
*
