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Consultation & PERFORMANCE Pen order form

Please complete our patient consultation form below.  A trained and licensed healthcare professional will respond to you.  We are proud to offer the exclusive PERFORMANCE Pen.  An elegant, discreet pen than can solve Erectile Dysfunction in 99% of patients - including those for whom Viagra won't work. 

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Consultation & PERFORM Pen Order Form

Medical History:  

Please note any of the following: 

Do you have any other pre-existing conditions?

Vital Signs:   

Height

Weight

Blood Pressure

Pulse

Temperature

Present Complaint

History of complaint: 

When did it start?

PERFORM Pens 
$250 each

PERFORM Refills 
$200 each

Please check all that apply

Thank you! We’ll be in touch.

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