Please fill out all required questions. You must do the CAPCHA math equation at the end to submit the form. After you fill out the form, please go to the top of this page and Click on the BOOK button to schedule. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *What is your date of birth? *How did you hear about the O shot?When was your last menstrual period?Have you been through menopause? *YesNoIf you are postmenopausal, are you on hormone replacement?YesNoHave you had a hysterectomy?YesNoIf you have had a hysterectomy, do you still have your ovaries?YesNoPlease check off any if you have any of these medical conditionsDiabetesHypertensionAutoimmune conditionLow thyroidHistory of cancerHeart diseaseOtherPlease list any other medical conditions you haveAre you on any medications?YesNoPlease list your medicationsDo you have vaginal dryness?YesNoIf yes, how long have you had it. Have you tried anything? The O shot uses PRP injections to improve Intimate Wellness for women. It can help with dryness, leaking and orgasm. What are you wanting to see improve? *Vaginal drynessBladder leakingSexual functionImproved vaginal/vulvar healthDo you have bladder leaking?YesNoPlease check off if true for you,I leak with coughing or sneezingI have to rush to the bathroomI have to wear pads due to leakingI limit my water intake because of concerns about leakingI leak without warningI avoid exercise because of concern about leakingIf you answered yes to any of the above questions, how long have you had the concerns? Is there anything that you have tried to help?Is sex less enjoyable now?YesNoWas there a time when sex was more enjoyable?YesNoAre you having issues with achieving orgasm?YesNoHas your libido changed?YesNoHave you had your testosterone level checked?YesNoHave you tried anything to help? *Have you had any surgeries?YesNoPlease list any surgeries that you have had. Have you had a GYN exam and Pap smear in the past year? *YesNoDo you have any children?YesNoIf yes, did you have any difficult deliveries or larger babies?YesNoDid you have any bad tears with vaginal deliveriesYesNoPlease give more detail on any GYN concern you may have had recently have ie pain with sex, vaginal discharge, infection or heavy bleeding.Are you ready to book your Virtual Consultation? If yes, please text us at 770-649-0094 *YesNoWe want to make the most of your time and the doctors. Have your read thru the O shot site and learned about the procedure and the Pricing options? *YesNoCan we text you? *YesNoProve you are human-Custom Captcha * = SUBMIT ← Back to home page of website
