Regenmaxx BioJust Form

1

Have you experienced any of the following issues?* This field is required.

I just want to please my partner the best I can

I have to rely on pills to get an erection

I can't perform like I used to

I have circulation issues

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

2

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

YESNO

3

How has this issue affected your quality of life?* This field is required.

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

4

How soon do you want this fixed?* This field is required.

Immediately

Within a month

Within 3 months

Within 6 months

It's really not a problem for me

6

What questions would you like to ask us during your consultation?* This field is required.

How quickly does REGENmax work?

Will I need more than one treatment?

Is it painful or uncomfortable?

What's the cost of REGENmax?

Other

7

Name* This field is required.

First Name

Last Name

8

Email* This field is required.

example@example.com

9

Phone Number* This field is required.

Please enter a valid phone number.