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e-Women Low Libido Form
Baal Perazim revolutionary Women Low Libido Therapy
6
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1
Tell us your name
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Lets us know who you are.
First Name
Last Name
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2
Lets triage Libido issue
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Tell us about your low libido in your own words. If you are purchasing for your female companion- give us your perspective. Here are tips: When did it start? What makes it better? What has been attempted thus far?
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3
Tell us your age or the age of your female companion?
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4
Provide us with your contact and your pharmacy information
*
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Telemedicine Instructions will be sent to the provided email within 3 hrs of submitting this request.
WHAT IS YOUR EMAIL ADDRESS?
WHAT IS YOUR PHONE NUMBER?
WHAT IS YOUR PHONE NUMBER?
Provide us with your pharmacy information. You also have a choice of having them mailed to you (usually take 24-48hrs)
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5
Give consent to be treated by our health professionals
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YES, I consent
NO, I do not consent
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6
We have a diverse staff. Our Health Professionals consists of qualified Medical Doctors, Certified Nurse Practitioners and Physician Assistants
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I understand
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NO
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