Let's Talk Erectile Dysfunction - No Shame, Just Solutions

Submit your free intake form today—no commitment required. A licensed provider will review your info within 48 hours.

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Step 1 of 14

What is your email?*

Are you currently an active patient in Ness’ weight loss program?*

Yes

Would you like to bundle your ED medication with your medical weight loss prescription?*

We highly recommend bundling with our medical weight loss program, as you can save up to 45% off your medication.

Yes

Which GLP-1 are you currently taking, as prescribed by Ness?*

How do you rate your confidence that you can get and keep an erection?*

Very Low

Low

Moderate

High

Very High

When you have erections with sexual stimulation, how often are your erections hard enough for penetration?*

Almost never or never

A few times (less than half the time)

Sometimes (about half the time)

Most times (more than half the time)

Almost always or always

How often are you able to maintain your erection for a long enough period to satisfy yourself or your partner?*

Almost never or never

A few times (less than half the time)

Sometimes (about half the time)

Most times (more than half the time)

Almost always or always

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?*

Extremely Difficult

Very Difficult

Difficult

Slightly Difficult

Not Difficult

When you attempted sexual intercourse, how often was it satisfactory to you?*

Almost never or never

A few times (less than half the time)

Sometimes (about half the time)

Most times (more than half the time)

Almost always or always

How did you ED begin?*

Gradually, but it worsened over time

Suddenly, but not with a new partner

Suddenly, with a new partner

I don't know how it began

How satisfied have you been with your overall sex life?*

Not at all

A little bit

Somewhat

Quite a bit

Very

Which treatment option best fits your needs?*

Have you ever taken ED medication before?*

Yes

Please list medication(s) previously tried:*

Have you ever been diagnosed with or treated for high or low blood pressure?*

Yes, I have been diagnosed or treated for high blood pressure

Yes, I have been diagnosed or treated for low blood pressure

I’m not sure

Have you ever been diagnosed with any of these heart conditions? (Please check off all that apply)*

None of these

Arrhythmia

Coronary artery disease (narrowing of the heart vessels)

Coronary bypass surgery

Heart attack

Idiopathic Hypertrophic Subaortic Stenosis (aka hypertrophic obstructive cardiomyopathy)

Long QT Syndrome

Any congenital or developmental heart problems

Pulmonary HTN (a rare condition that refers to the blood vessels to the lungs and isn't the same as high blood pressure)

Heart failure

Do you experience any of these symptoms? (Please check off all that apply)*

None of these

Chest pain while climbing stairs or walking

Chest pain during sexual activity

Sudden loss of vision due to loss of blood flow to your eye (aka anterior ischemic optic neuropathy)

Unexplained fainting or dizziness

Cramping or pain in the calves or legs with exercise (aka claudication)

Have you ever been diagnosed with or experienced the following? (Please check off all that apply)*

None of these

Kidney failure, disease, or dialysis

Liver disease

Nonarteritic anterior ischemic optic neuropathy (NAION)

Diabetes

Told not to have sex for any reason

Sickle Cell Anemia

Stroke

Peyronie’s disease or pain with erections

Foreskin that’s too tight

Active stomach, intestinal, or bowel ulcers or bleeding

Bleeding disorder (causing you to bleed more easily than is normal)

Multiple sclerosis, paralysis, or spinal cord injury

Clotting disorder (you form clots more easily than is normal)

Have you used any of these recreational drugs in the last 6 months? (Please check off all that apply)*

Crystal meth (methamphetamines or amphetamines)

Poppers or Rush

Amyl Nitrate or Butyl Nitrate

Cocaine

Molly (MDMA, ecstasy)

No, I haven’t used these recreational drugs in the last 6 months

Please list all current medical conditions. Please type N/A if none.*

Please list all of your known allergies. Please type N/A if none.*

Do you currently use or have prescriptions for any of these medications?*

None of these

Any medication containing nitrates

Any ALPHA blocker, NOT beta blocker (like Flomax, Cardura, and Minipress)

Nitroglycerin in any form (Spray, tablet, patch, or ointment)

Supplements that boost nitric oxide (like L-arginine, L-citrulline, beet root powder/extract/juice concentrate)

Monoket (isosorbide mononitrate), Bidil, or Isordil (isorbide dinitrate), which are commonly prescribed to prevent chest pain caused by heart disease

Antiretrovirals or any treatment for HIV

Adempas (riociguat)

Please list all prescriptions or over-the-counter medications and supplements you are currently taking. Please type N/A if none.*

Tell Us About Yourself

Name*

First Last

Phone Number*

Date of Birth*

MM slash DD slash YYYY

Sex at Birth*

Female

Male

Please upload a government-issued form of ID (Driver’s License, Passport, etc.). Please be sure that your full name and photo are easily visible.*

Max. file size: 5 MB.

What type of consultation would you prefer?*

Email and Text Message (Fastest Option)

Video

Phone Call

Expected Timelines: Email & Text - intake reviewed within 48 hours | Video or Phone - approval may take 5-7 days

How did you find Ness?*

Consent*

ED can be a sign of other undiagnosed medical issues like heart problems. Smoking, marijuana use, obesity, depression, and low testosterone can all play a role in erectile function (and dysfunction). In addition to seeking ED treatment, we recommend you speak with your primary care provider to rule out other underlying conditions.

I understand

Consent*

Please attest to the following confirming that all the information you provided is true and complete. If you do not agree, you may not submit this form. I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care.

I agree and consent

Ness doctors review every form within 24 hours. Do you have any further information which you would like the doctor to know?

One Last Step

We'll securely collect your payment information now, but you won't be charged until your intake form has been reviewed. If you qualify for medical weight loss, your first month’s prescription will be billed at that time. If you're not eligible, a $30 non-refundable evaluation fee will be charged to cover the cost of the medical review.

Promo Codes

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Is your shipping address the same as billing?*

Yes

Billing Address

Street Address Address Line 2 City State ZIP Code

Use code YESNESS at checkout for a discounted first month!

Let's Talk Erectile Dysfunction - No Shame, Just Solutions

Tell Us About Yourself

One Last Step

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