Apply for Services

Name *

First Name

Last Name

Phone *

Please leave your phone number so I may text to schedule a complimentary phone call to discuss services.

(###)

###

####

Gender *

Male

Female

How would you rate your libido (sex drive)? *

Terrible

Poor

Average

Good

Excellent

How would you rate your energy level? *

Terrible

Poor

Average

Good

Excellent

How would you rate your strength and endurance? *

Terrible

Poor

Average

Good

Excellent

How would you rate your enjoyment of life? *

Terrible

Poor

Average

Good

Excellent

How would you rate your happiness level? *

Terrible

Poor

Average

Good

Excellent

How strong are your erections? *

1 being extremely weak and 5 being extremely strong

1

2

3

4

5

How would you rate your work performance over the past 4 weeks? *

Terrible

Poor

Average

Good

Excellent

How often do you fall asleep after dinner? *

Never

1-2 times/week

3-4 times/week

5-6 times/week

Every night

How would you rate your sports ability over the past 4 weeks? *

Terrible

Poor

Average

Good

Excellent