Patient Questionnaire

We appreciate your participation in our questionnaire. The best possible way for us to improve our services is to hear from you, the people we are here to serve.

Many people have fixable problems that they endure instead of treat, especially women with leaking problems and men with erectile dysfunction. These conditions are both prevalent and underreported.

Your success story may be an invaluable aid and inspiration to someone else who is suffering with the same condition and is wondering if he or she should seek treatment. You can play a part in ending someone’s suffering simply by telling your story.

Your responses are private and confidential. Please feel free to answer anonymously if you’d like.

Thank you for your feedback, it’s invaluable to us.

First Name:	Please enter your First Name
Last Name:	Please enter your Last Name
Street address:	Please enter your street address
City:	Please enter your city
State:
Zip code:
Telephone:
E-mail:*	Please enter your email address.

Patient Questionnaire

Thank you for your feedback, it’s invaluable to us.

Patient Questionnaire

Please only respond to the questions that seem relevant to you.

Type of Treatment:

Overall Experience:

Experience with Doctor(s):

Experience with Administrative Staff: