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Enter Your Information Below
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1.
What is your name?
(Required.)
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2.
What is your age?
(Required.)
Under 18
18-30
31-40
41-50
51-60
61-70
70-80
80+
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3.
What is your current relationship status?
(Required.)
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4.
What is your occupation?
(Required.)
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5.
Where are you based? (City and country)
(Required.)
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6.
Please describe your experience with Erectile Dysfunction (E.D.)
(Required.)
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7.
How long have you had E.D.?
(Required.)
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8.
What other methods of tackling E.D. have you tried, if any?
(Required.)
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9.
Why do you see therapy as an important way of tackling E.D.?
(Required.)
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10.
How has E.D. impacted your life, relationships and confidence?
(Required.)
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11.
If you ended E.D. today what would it mean to you and how would it change your life?
(Required.)
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12.
If you knew with absolute certainty that therapy would help end your ED and give you the sex life you always wanted, what would that be worth to you?
(Required.)
Less than $100
$100-$1k
1-4k
4-10k
10k+
13.
Do you have any other questions or comments you would like to add?
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14.
What’s your best e-mail address (Gary will use this to arrange the call if you’re a good fit)?
(Required.)
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15.
Please re-confirm your e-mail address below
(Required.)
16.
What's the best phone number to contact you on? (Optional)
17.
What's your skype address? (Optional)