Treating the causes, not just the symptoms Hope to chronic sufferers Pain Free Treatment Promotes Spontaneity and a Natural Sex Life

Confidential Medical Questionnaire

This questionnaire is confidential; it will never be shared with anybody other than the Clinical Staff and those involved in your treatment. It is stored in a secure, confidential manner and all electronic communications are encrypted to ensure confidentiality.

Contact Details

About Your ED

Unfortunately this renders you unsuitable for this treatment

Current and recent use of medicines

Your Medical History

Unfortunately this renders you unsuitable for this treatment

Heart, Health & Blood Pressure

Unfortunately this renders you unsuitable for this treatment

Diabetes and blood sugar levels

General Medical History

Lifestyle Factors

Please enter your height, weight & waist (Imperial Units)

Informed Consent