Gulf Coast Medical Associates

1

Are any of the following true?* This field is required.Select all that apply & click NEXT

I can't perform like I used to

I have to rely on pills to get an erection

I have circulation issues

I have Peyronie's disease (curved, painful erections)

I just want to please my partner the best I can

2

Have you been diagnosed by a professional?* This field is required.

Yes

No

3

What was the diagnosis?* This field is required.

4

How has this issue affected your quality of life?* This field is required.Select all that apply & click NEXT

I'm less confident initiating sex than I used to be

I feel embarrassed by it, even though it's not my fault

I can't be spontaneous with sex anymore

I deal with the side effects of the pills

I'm frustrated by the lack of sex this issue causes

5

When did you start considering acoustic wave therapy ED treatment?* This field is required.Select one

I've been thinking about it for over a year

In the last 6-12 months

1-6 months ago

In the last month

I just found out about it.

6

What ED treatments have you spent money on?* This field is required.Select all that apply & click NEXT

Erection pills

Penis pump

Natural supplements

Testosterone (pills or injection)

Trimix

None

Other

7

What questions would you like to ask us during your consultation?* This field is required.Select all that apply & click NEXT

How quickly does acoustic wave therapy work?

Will I need more than one treatment?

Is it painful or uncomfortable?

What's the cost of acoustic wave therapy?

Other

8

What day in the next week can you come in for your consultation?* This field is required.Select one

Monday

Tuesday

Wednesday

Thursday

Friday

9

Can We Get A Name?* This field is required.Enter first and last name

First Name

Last Name

10

Where Can We Send More Information?* This field is required.Enter best email address

11

Please Verify Your Cell Phone Number* This field is required.We'll text you a 5 digit code

12

What is your date of birth?* This field is required.Enter your date of birth and click SUBMIT.