Please enable JavaScript in your browser to complete this form.Take Our O Shot Self Test. You must fill out all required questions. And you must do the CAPCHA math equation at the end to submit the form. Date / TimeDateTimeName *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 medicationsIs sex less enjoyable now?YesNoWas there a time when sex was more enjoyable?YesNoAre you having issues with achieving orgasm?YesNoHas your libido changed?YesNoIf 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?Have you had your testosterone level checked?YesNoDo you have vaginal dryness?YesNoIf yes, how long have you had it. Have you tried anything? Do 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 your water intake because of concerns about leakingI leak without warningI avoid exercise because of concern about leakingI limit outings because of concerns you may leanHave 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, book here https://tinyurl.com/2p8uzx3u. You may need to copy and paste link. YesNoProve you are human-Custom Captcha * = SUBMIT After you have filled out the O shot Self Text, please click the button below to scheduled your O shot Consultation. BOOK APPOINTMENT FOR O SHOT VIRTUAL CONSULTATION ← Back to home page of website
