Begin Assessment

Before we begin, we will ask for two details so we can save your
place, keep your session secure, and send your personalized
results.

Full Name *

Email *

Phone *

Country(if outside US)

Your information is used only to guide your experience and

communicate about your results. You will not be added to any

marketing list without your permission.

State

Consent & Contact

Would you like to be connected with a personal Concierge Coordinator?

Yes

No, I prefer to explore on my own

How did you hear about EDIN Vitality?

Impact & Duration

Has ED affected your happiness or relationship satisfaction? *

Yes

How long have you experienced ED symptoms? *

Current Function & Treatment History

Which best describes your current erectile function? *

Have oral ED medications failed you or caused side effects? *

Yes

Have you noticed a loss of penile length or girth? *

Yes

Not sure

Curvature / Peyronie's Screening

Do you experience penile curvature during erection? *

Yes, it affects function or causes discomfort

Yes, mild but doesn't bother me

Have you been diagnosed with Peyronie's disease? *

Yes

Suspected but not confirmed

Education Acknowledgment

Do you understand that a prosthesis uses your own penis and preserves sensation and orgasm? *

Yes

Did you know that 96% of men and 91% of partners report satisfaction after penile prosthesis surgery? *

Yes

Are you aware that outcomes are significantly better with high-volume, specialized surgeons? *

Yes

Surgeon Selection & Travel

Are you willing to travel 3–5 days to see a top regional surgeon? *

Yes

What matters most when choosing a surgeon? *

Experience and skill

Reputation and patient reviews

High procedure volume per year

Must be located near me, even if less experienced

Select your preferred region / surgeon (multi-select) *

Financial Readiness

How do you plan to cover treatment costs? (Insurance typically does not cover prosthesis surgery) *

Self-pay / Out of pocket

Financing

Insurance only — will not proceed if denied

Insurance first, then self-pay if denied

Insurance already denied — ready to self-pay

Medicare Part A & B

Timing & Readiness

How soon are you looking to schedule a consultation? *

As soon as possible

Within the next 1–3 months

3–6 months out

Just researching for now

Would you like to schedule a discreet consultation? *

Yes

Consent & Compliance

Preferred contact method

Communication Preferences *

I agree to receive additional educational content and updates from EDIN Vitality

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Privacy Consent *

I understand my information will be stored and processed to provide the services I've requested.