Sexual Wellness Intake - Women
Provide your details and preferences to help us understand your needs and offer personalized options.
First Name
*
Last Name
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Call
Text
How did you hear about us?
*
Please Select
Google Search
Instagram
Referral
Other
Which symptoms are you experiencing? (Select all that apply)
Low libido or decreased desire
Difficulty with arousal or orgasm
Vaginal dryness or discomfort
Pain or discomfort with intimacy
Perimenopause or menopause changes
Medication-related sexual side effects
Hormonal changes affecting intimacy
Other
Which treatment options would you like more information about? (Select all that apply)
PT-141 (Bremelanotide)
Arousal creams (compounded)
Hormone optimization (BHRT)
O-Shot®
Clitoxin®
Vampire Wing Lift
General consultation
Not sure yet
Is there anything else you'd like us to know before we reach out?
Submit
Should be Empty: