Please Complete this Form giving as much information as you can...We TREAT Chronic Prostatitis and Pelvic Inflammatory Disease with astounding results.
















Detailed Information Required

Tell us as much as you can about your Prostatitis, Pelvic Inflammatory Disease, Infertility History..

Here's a list of Details Required, feel free to add anything else you think is helpful:
  • Exactly what you suffer from: prostatitis, urethritis, epididymitis, sexually transmitted disease, other genital/urinary infections, PID, Infertility. State how long you have suffered from these conditions.
  • Detail your symptoms: frequent urination, pain, burning,impotence, itching, etc. State how long you have experienced these symptoms.
  • Have any pathogens ever been identified? State any related testing reports you have that we can ask you to email to us.
  • Have you ever had Genitourinary surgery, if so also state details.
  • What antibiotics and/or other medications have you taken in the past and for how long?
  • What antibiotics and/or other medications are you currently taking and for how long?
  • Describe your overall health and include any other medical issues that you currently have.
  • Has your sexual partner ever had a genitourinary infection? If yes, please explain in detail.
  • Do you have anything else to add about your condition?
  • We TREAT Chronic Prostatitis and Pelvic Inflammatory Disease with astounding results.

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