Consultation

Please fill in the following information to the best of your abilities, along with your credit card information, so that when I contact you for the consultation, I will have a better idea of what we are dealing with. This information is being submitted via a secure server to protect your privacy.

If you would like to fill out this form and print it for an office visit you may do so.
Office number: 717 747-0713

Client Questionnaire for Consultation and Lust Cream

Your Name :
Telephone (include area code) :
E-mail :
What is your chief complaint? (please be as specific as possible) :

Sexual Functioning

Any Medications? :
Genital Hygiene (ex. soaps, douches) :
Allergies? Sensitive to anything? :
Age / Date of Menopause :
Recent Change in Sexual Desire? :
For How Long? :
Do you experience pain during intercourse? :
For How Long? :
Please describe the pain, and where it occurs :
Does this pain occur :
Foreplay? :
Would you consider your arousal :
Are you orgasmic? :
Any Dryness, Erythema, Pruritis, or Discharge in your Genital area? :
How would you describe your sexual desire over the last month? :
Frequency of Intercourse last month :
How often did you experience orgasms? : (percent)
Do you smoke? :
If so, how many per day? :
Do you drink? :
How many drinks per week? :
Any Changes in : Sleep?
Appetite?
Moods?
Weight?
Do you have any Chronic Diseases? (If so, please list) :
Do you currently, or in the past, have had any form of cancer? :
   

Credit Card Information to Order Novel, Consultation or Cream

Name as printed on the card :
Address :
Email :
Telephone Number :
Card Type :
Credit Card Number :
Expiration Date :
CSC :
How many 5cc Syringes are you ordering (@ $15.00 each)? :
A Shipping and Handling charge of $4.50 will be added to each order. Your credit card will be billed when the order is shipped.
Order Novel :
The cost of the book is - Soft Cover:$14.00, Dust Cover:$21 plus 4 for shipping and handling plus 6% sales tax if mailed in PA.

By clicking the “SUBMIT” button below, you will be sending this information via a secure server to Dr. Rebecca Burdette. Your payment will be processed when Dr. Burdette is ready to contact you for the consultation. By clicking the “Submit” button, you give permission for Dr. Burdette to review this information, and contact you via telephone for your consultation. You also authorize to allow your credit card listed above to be charged the amount of $50.00 for the consultation prior to your call.

Comments are closed.