WE WOULD LIKE TO HEAR FROM YOU

Fill out the form and we’ll get in touch with you as soon as possible. We usually take between 12-24 hours to arrange a consultation time. You are not obliged to accept the consultation by any means. This service is offered completely free of charge. You do not need to be a member to use this service, since it is free for the public.

Your personal information will not be disclosed to any third parties by any means. Confidentiality guaranteed.

PERSONAL INFORMATION
First and Last Names
Email:
# Phone :	Not required
Address:	Not required
Line 2:	Not required
City:
State / Province:
Postal Code :
Country:
PERSONAL INFORMATION
Age
Do you have a partner?	Si No
How long have you had PE?	From adolescence Over 3 years 3 years 2 years 1 year Less than 6 months
How frequent is your PE?	Always Most of the time Some times
How long can you “last”?	5-10 min 1-5 min 1 min or less As soon as a penetrate Sometimes before penetrating
Do you use any numbing agents? Creams, sprays, etc.	No, never I use them frequently I have tried them
Do you suffer or have you suffered recently from emotional tension or stress?	Yes No
Comments: (Include any inquiries and/or specify the details of your condition)