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Thank you for your interest in working with us. This form will help us better understand your needs so that we can match you with the ideal specialist. Your information is secure and only shared with our clinical team. We do NOT sell your information.

Name

First Name

Last Name

Location (City)

Currently we service the Greater Atlanta Metro Area

Which of the following conditions are you most interested in seeing a specialist for?

Erectile Dysfunction

Low Testosterone

Enlarged Prostate / Overactive Bladder

Prostate Cancer Screening / Treatment

Other

Briefly describe what you have tried or any relevant info to help us find your specialist. If you are looking for something specific, you may also name that here.

Optional

I am willing to see an Advanced Practice Provider (P.A. or N.P.)

We will only match you with an APP who specializes in the diagnosis/treatment you seek.

Yes

No Thanks

Let’s get started.

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