Private IPP Eligibility Check

60 seconds · Confidential · No obligation

This private form helps determine whether inflatable penile prosthesis (IPP) surgery is an appropriate next step and how to proceed efficiently.

Your information is reviewed discreetly and used only to coordinate next steps. Completing this form does not obligate you to treatment.

First Name *

Email *

Phone *

Age *

State (Country if outside US) *

How did you first learn about Edin Vitality? *

How long have you been experiencing erectile dysfunction symptoms?

How would you most likely plan to cover treatment costs if you move forward? *

Direct self-pay (credit, debit, or wire)

Monthly financing (flexible payment options available)

Insurance first, with self-pay or financing if denied

Medicare Part A & B

Have you tried other erectile dysfunction treatments? *

Oral medications (e.g., Viagra, Cialis)

Injections (e.g., Trimix)

Vacuum devices

None yet

Anything you’d like us to know, or any questions you’d like answered?

Information Handling *

I consent to the secure handling of my information.

I understand that the information I provide may include protected health information (PHI) and consent to its confidential use for eligibility review and follow-up related to my inquiry.

Communication Preference *

I agree to be contacted privately regarding next steps.

This may include phone, text, or email communication. All contact is discreet.