Erectile Dysfunction (ED) Consent Form

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Referral Name* This field is required.
Dimitri Frangoulias
Type option 2
Type option 3
Type option 4
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Full Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
4
Current Weight (in lbs)* This field is required.
5
Where Are You Located?* This field is required.
City
State
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Phone Number* This field is required.
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Email* This field is required.
example@example.com
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How often do you have trouble achieving or maintaining an erection?* This field is required.
Rarely
Occasionally
Often
Always
Other
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When did you first notice symptoms of erectile dysfunction? * This field is required.
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Are your erections less firm than they used to be?* This field is required.
Yes
No
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Do you wake up with morning erections?* This field is required.
Yes
No
Sometimes
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Do you experience sexual desire or libido?* This field is required.
High
Moderate
Low
None
Other
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Do you exercise regularly?* This field is required.
Yes
No
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How many hours do you sleep per night?* This field is required.
Less than 5 hours
Less than 6 hours
Less than 7 hours
Less than 8 hours
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Do you smoke or vape?* This field is required.
Yes
No
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Do you consume alcohol?* This field is required.
Yes
No
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Do you use recreational drugs?* This field is required.
Yes
No
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Rate your current stress level* This field is required.
Low
Moderate
High
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Please review the following conditions and check any that apply to your medical history or current health status, as they may impact treatment eligibility.* This field is required.
Diabetes
High Blood Pressure
High Cholesterol
Heart Disease
Low Testosterone
Depression or Anxiety
Prostate Issues
Sleep Apnea
None of the above
Other
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I understand that a licensed medical provider will review my intake form and medical history to determine if this therapy is appropriate for me. No medication will be prescribed without clinical justification and professional medical judgment.
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What are your treatment goals?* This field is required.
Improveerection firmness
Increase sexual performance and stamina
Restorelibido and sexual desire
Improveconfidence and reduce performance anxiety
Enhance overall quality of life
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Monitoring and Follow-Up

I agree to participate in periodic follow-up visits and/or lab testing to assess my response to therapy. I understand that adjustments may be made to ensure the safest and most effective outcome.
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Please read and acknowledge the following disclosures to ensure informed consent and compliance with medical and legal standards.* This field is required.
I acknowledge that this treatment may includeoff-label or compounded formulations.
Iconsent to receive therapy via telehealth and understand that all evaluationsand recommendations comply with state law.
I understand that Koreme Anti-aging & Aesthetics Group and its providers arenot liable for adverse reactions due to undisclosed history, misuse, ornoncompliance.
I understand that I may stop therapy at any time and that doing so will not affect my right to receive future care.
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Consent for Treatment

I have read and understand this consent form. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. I voluntarily consent to begin Testosterone Replacement Therapy under the supervision of a licensed medical provider.
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Signature* This field is required.Please sign below to confirm that the information provided is accurate and that you have read and understood the above acknowledgments.
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