RejuvaMAX Enhancement Intake Form
The medical information you supply is subject to ALL patient/doctor privilege laws
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Employment Status - Employer? Self-Employed? Retired?
Relationship to patient
Do you have any allergies? Please list
Are you allergic to Lidocaine or local anesthetics?
Are you allergic or sensitive to Hyaluronic Acid fillers?
List All Medical Conditions
List All Current medications including prescriptions, over-the-counter and supplementsa
Are you currently taking any prescription blood-thinners such as warfarin, Eliquis, Xarelto etc?
Are you currently taking any OTC aspirin or non-steroidal anti-inflammatory drugs?
Are you currently taking Vitamin E supplements or herbal supplements containing garlic or ginkgo bilboa?
Do you have diabetes?
Do you suffer from Porphyria?
Do you have a tendency to form keloids or hypertrophic scarring?
Do you have genital herpes or any sexually transmitted disease?
If yes, please provide details of the herpes or STD. How often have outbreaks? Treatment? Current outbreak?
Please describe why you are seeking Penile Enhancement Procedure? Concerns about Girth? Length? Irregular shape....?
Have you tried any treatments or penis enlargement treatments in the past?
How long have you been concerned about penis size and what have your tried in the past?
Please check all conditions that apply:
Penile size concerns
Irregularities in penile shaft
Are you circumcised?
On a scale of 0 to 100%, how firm are your natural erections. Are the firm enough for penetration during sexual intercourse?
How frequently do you get morning erections?
Can you feel a lump or scar tissue inside your penis? If yes, please describe size and location.
Do you experience pain or discomfort when you have an erection?
Do you experience pain or discomfort during sexual intercourse?
Can not have intercourse
Please tell us your reason you are seeking Penis Enhancement and your expectations
Are you seeking Penis Enhancement because you are troubled by the size of your penis or because your partner is having issues (woman's vaginal area stretches out with childbirth and age)
Individual concerns about size and appearance
To satisfy partner
Do you Smoke
Do you consume alcoholic beverages?
Do you use marijuana, cocaine or other similar drugs?
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