Begin Your Assessment

60 seconds · Confidential · No obligation

This private form helps us understand your situation and connect you with the right next step. Your information is reviewed discreetly and used only to coordinate your consultation.

What brings you here today? (NOTE: Financing options ARE AVAILABLE) *

Have you had any prior procedures, injections, or fillers in the area? *

How long have you been experiencing erectile dysfunction symptoms? *

Have you tried other erectile dysfunction treatments? *

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

Injections (e.g., Trimix)

Vacuum devices

None yet

Note: Our surgeons work on a self‑pay basis only for penile implant procedures. Because of inconsistent insurance coverage, frequent denials, significant hospital balance billing, and last‑minute cancellations, EDIN procedures are not offered through insurance. In practice, most insurance plans deny coverage for this surgery or leave patients with large, unexpected hospital bills. With Edin Vitality, you receive (1) Transparent, all‑inclusive pricing (2) Fast, predictable scheduling with top surgeons (3) Concierge‑level support and privacy. (4) No surprise hospital balance bills. If you would only move forward using insurance, this program will unfortunately not be a good fit. If you are exploring EDIN as a top‑surgeon, self‑pay option, please choose the payment approach that fits you best. *

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

Monthly financing (flexible payment options available)

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

Full Name *

Email *

Phone *

Age *

State (Country if outside US) *

How did you first learn about Edin Vitality? *

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.